| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
300 |
300 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
237 |
237 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
90 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
23 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
17 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
38 |
$0.00 |
| D1110 |
Prophylaxis - adult |
231 |
231 |
$0.00 |
| D1120 |
Prophylaxis - child |
74 |
74 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$0.00 |