| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,190 |
955 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
607 |
602 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,104 |
1,804 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
362 |
361 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
410 |
409 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,181 |
952 |
$13K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$12K |
| D1120 |
Prophylaxis - child |
317 |
314 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
851 |
843 |
$10K |
| D0350 |
|
461 |
192 |
$4K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
25 |
$3K |
| D4910 |
|
12 |
12 |
$924.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |