| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
694 |
694 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
92 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$3K |
| D0603 |
|
57 |
57 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
356 |
356 |
$125.39 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
69 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
343 |
343 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
37 |
37 |
$0.00 |
| D0601 |
|
27 |
27 |
$0.00 |