| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9410 |
|
1,226 |
1,033 |
$60K |
| D1110 |
Prophylaxis - adult |
393 |
393 |
$23K |
| D1206 |
Topical application of fluoride varnish |
362 |
361 |
$14K |
| D1330 |
|
576 |
564 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
252 |
252 |
$7K |
| D0190 |
|
206 |
206 |
$4K |
| D0191 |
|
110 |
110 |
$2K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D4910 |
|
19 |
19 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$735.00 |
| D9920 |
|
20 |
20 |
$660.00 |