| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
263 |
196 |
$32K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$58.00 |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
16 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$0.00 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
105 |
104 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
21 |
21 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
22 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
22 |
$0.00 |