| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,585 |
1,583 |
$94K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$600.82 |
| D0120 |
Periodic oral evaluation - established patient |
1,463 |
1,461 |
$301.21 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$217.71 |
| D0274 |
Bitewings - four radiographic images |
243 |
243 |
$142.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
494 |
493 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$0.00 |