| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
435 |
435 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
296 |
295 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
264 |
264 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,065 |
1,063 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
163 |
163 |
$7K |
| D9430 |
|
206 |
179 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
38 |
$6K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
158 |
$2K |
| D0350 |
|
119 |
56 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$820.80 |