| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
311 |
305 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
330 |
322 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
83 |
$0.00 |
| D1320 |
|
316 |
309 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
151 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
26 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
24 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
20 |
17 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
208 |
205 |
$0.00 |
| D1110 |
Prophylaxis - adult |
186 |
180 |
$0.00 |
| D0330 |
Panoramic radiographic image |
158 |
156 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
382 |
368 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
40 |
$0.00 |