| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
769 |
769 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
869 |
867 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
585 |
585 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,252 |
1,249 |
$20K |
| D1120 |
Prophylaxis - child |
328 |
328 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
179 |
$9K |
| D4910 |
|
83 |
83 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
49 |
$5K |
| D0350 |
|
97 |
44 |
$931.20 |
| D9430 |
|
26 |
26 |
$832.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$212.00 |