| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
2,742 |
2,309 |
$87K |
| D1110 |
Prophylaxis - adult |
733 |
733 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
801 |
543 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
918 |
914 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
723 |
721 |
$44K |
| D4910 |
|
562 |
562 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
543 |
345 |
$43K |
| D0350 |
|
3,996 |
1,131 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
750 |
747 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,391 |
1,616 |
$26K |
| D4341 |
|
451 |
119 |
$26K |
| D1206 |
Topical application of fluoride varnish |
898 |
897 |
$14K |
| D0274 |
Bitewings - four radiographic images |
367 |
366 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
604 |
604 |
$7K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
223 |
$3K |
| D2394 |
|
17 |
13 |
$1K |
| D2920 |
|
21 |
14 |
$882.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D0270 |
|
13 |
13 |
$65.00 |