| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,188 |
868 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
607 |
604 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
340 |
340 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
346 |
346 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,259 |
575 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
111 |
62 |
$7K |
| D0274 |
Bitewings - four radiographic images |
360 |
353 |
$7K |
| D1120 |
Prophylaxis - child |
202 |
198 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
319 |
319 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
18 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
17 |
$2K |
| D2140 |
|
33 |
13 |
$2K |
| D0350 |
|
52 |
13 |
$499.20 |
| D1999 |
|
12 |
12 |
$0.00 |