| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$0.00 |
| D1120 |
Prophylaxis - child |
21 |
21 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
93 |
$0.00 |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
110 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
81 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
32 |
$0.00 |