| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9410 |
|
1,456 |
1,322 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,474 |
1,471 |
$27K |
| D1110 |
Prophylaxis - adult |
1,336 |
1,336 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
313 |
248 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
320 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
74 |
$4K |
| D1120 |
Prophylaxis - child |
221 |
221 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
269 |
269 |
$2K |
| D9920 |
|
43 |
43 |
$650.00 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$386.00 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$202.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$40.00 |