| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,818 |
1,328 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
642 |
641 |
$31K |
| D1110 |
Prophylaxis - adult |
361 |
360 |
$29K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
59 |
41 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
345 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,460 |
1,166 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
864 |
826 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
142 |
$6K |
| D1120 |
Prophylaxis - child |
181 |
178 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
15 |
$4K |
| D0274 |
Bitewings - four radiographic images |
184 |
183 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
85 |
$774.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$474.00 |