| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
146 |
146 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
136 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
130 |
130 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
168 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
127 |
127 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$0.00 |