| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
70 |
$0.00 |
| D0603 |
|
21 |
21 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
44 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
176 |
75 |
$0.00 |
| D0601 |
|
46 |
43 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
74 |
$0.00 |
| D1351 |
Sealant - per tooth |
80 |
21 |
$0.00 |
| D1120 |
Prophylaxis - child |
59 |
57 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
75 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
38 |
35 |
$0.00 |