| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
57 |
57 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
22 |
$0.00 |
| D1351 |
Sealant - per tooth |
85 |
23 |
$0.00 |
| D0603 |
|
39 |
39 |
$0.00 |
| D1330 |
|
62 |
62 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
40 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$0.00 |
| D1310 |
|
48 |
48 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
41 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$0.00 |
| D1120 |
Prophylaxis - child |
54 |
54 |
$0.00 |
| D9993 |
|
40 |
40 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$0.00 |