| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
385 |
377 |
$0.00 |
| D9910 |
|
282 |
215 |
$0.00 |
| D1120 |
Prophylaxis - child |
55 |
53 |
$0.00 |
| D0191 |
|
227 |
226 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
25 |
$0.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D1354 |
|
44 |
25 |
$0.00 |
| D1330 |
|
216 |
210 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
132 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
317 |
313 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$0.00 |
| D0603 |
|
215 |
212 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
323 |
249 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
374 |
366 |
$0.00 |
| D0602 |
|
175 |
175 |
$0.00 |
| D1351 |
Sealant - per tooth |
145 |
47 |
$0.00 |
| D0601 |
|
53 |
53 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$0.00 |