| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
22 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$0.00 |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$0.00 |