| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
807 |
750 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
232 |
$1K |
| D0330 |
Panoramic radiographic image |
123 |
115 |
$971.82 |
| D0274 |
Bitewings - four radiographic images |
463 |
455 |
$220.80 |
| D0220 |
Intraoral - periapical first radiographic image |
778 |
726 |
$78.26 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
191 |
$0.00 |
| D9630 |
|
405 |
405 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
499 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
260 |
249 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
595 |
595 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
393 |
393 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
138 |
107 |
$0.00 |
| D3120 |
|
16 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
261 |
151 |
$0.00 |
| D1120 |
Prophylaxis - child |
143 |
143 |
$0.00 |
| D1999 |
|
78 |
43 |
$0.00 |