| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
2,429 |
2,155 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
919 |
919 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
498 |
495 |
$36K |
| D1120 |
Prophylaxis - child |
531 |
525 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
447 |
446 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
117 |
$17K |
| D1110 |
Prophylaxis - adult |
159 |
159 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,865 |
1,654 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
837 |
830 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
643 |
578 |
$6K |
| D0274 |
Bitewings - four radiographic images |
244 |
244 |
$5K |
| D4910 |
|
55 |
55 |
$4K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$4K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$984.00 |