| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,200 |
843 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
521 |
$34K |
| D0350 |
|
3,261 |
889 |
$30K |
| D1110 |
Prophylaxis - adult |
293 |
293 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
510 |
501 |
$23K |
| D0330 |
Panoramic radiographic image |
292 |
286 |
$8K |
| D1206 |
Topical application of fluoride varnish |
459 |
459 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$935.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
233 |
131 |
$911.25 |
| D4910 |
|
12 |
12 |
$847.00 |
| D0270 |
|
12 |
12 |
$55.00 |