| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,929 |
1,600 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
948 |
944 |
$58K |
| D1110 |
Prophylaxis - adult |
394 |
392 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
742 |
739 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
413 |
413 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
347 |
185 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,016 |
835 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
987 |
982 |
$13K |
| D0274 |
Bitewings - four radiographic images |
584 |
583 |
$12K |
| D4341 |
|
94 |
26 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
16 |
$4K |
| D0350 |
|
295 |
144 |
$3K |
| D4910 |
|
36 |
36 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$840.00 |