| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$976.80 |
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$298.20 |
| D9994 |
|
175 |
164 |
$236.72 |
| D9992 |
|
154 |
143 |
$139.88 |
| D3120 |
|
27 |
14 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$0.00 |
| D9920 |
|
144 |
133 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
29 |
$0.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$0.00 |
| D1120 |
Prophylaxis - child |
53 |
53 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
17 |
$0.00 |