| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,193 |
1,184 |
$95K |
| D9410 |
|
2,598 |
2,467 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D2330 |
|
20 |
13 |
$636.02 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
37 |
$150.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
724 |
715 |
$13.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
187 |
187 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |