| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
439 |
439 |
$13K |
| D1206 |
Topical application of fluoride varnish |
753 |
753 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
631 |
631 |
$12K |
| D0251 |
|
1,248 |
669 |
$11K |
| T1015 |
Clinic visit/encounter, all-inclusive |
50 |
46 |
$9K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$5K |
| D8670 |
Periodic orthodontic treatment visit |
33 |
32 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$505.44 |
| D1999 |
|
377 |
367 |
$120.00 |