| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,267 |
908 |
$40K |
| D0350 |
|
1,401 |
303 |
$13K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
140 |
$11K |
| D1206 |
Topical application of fluoride varnish |
570 |
566 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$8K |
| D4910 |
|
96 |
96 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
41 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
115 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
272 |
$3K |
| D0274 |
Bitewings - four radiographic images |
66 |
66 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
57 |
$828.00 |
| D1310 |
|
14 |
14 |
$50.00 |
| D1330 |
|
14 |
14 |
$0.00 |