| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
2,073 |
1,560 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
900 |
896 |
$56K |
| D0350 |
|
5,560 |
1,575 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
540 |
230 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
793 |
792 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,411 |
1,315 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,196 |
949 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
23 |
15 |
$11K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
620 |
616 |
$8K |
| D1120 |
Prophylaxis - child |
171 |
171 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
126 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
54 |
$5K |
| D0274 |
Bitewings - four radiographic images |
187 |
187 |
$4K |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$223.50 |