| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
434 |
430 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
473 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
158 |
$810.90 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
235 |
124 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
137 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
212 |
210 |
$0.00 |
| D9994 |
|
118 |
118 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
75 |
75 |
$0.00 |
| D9920 |
|
32 |
31 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
89 |
$0.00 |
| D1110 |
Prophylaxis - adult |
297 |
297 |
$0.00 |
| D2950 |
|
123 |
85 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
69 |
45 |
$0.00 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$0.00 |