| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$0.00 |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
137 |
136 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
40 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
21 |
$0.00 |