| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
122 |
122 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
254 |
251 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
83 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$7K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$6K |
| D1206 |
Topical application of fluoride varnish |
106 |
106 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
257 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$2K |
| D0350 |
|
46 |
38 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |