| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
88 |
88 |
$0.00 |
| D1120 |
Prophylaxis - child |
75 |
75 |
$0.00 |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
179 |
$0.00 |
| D0270 |
|
39 |
39 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$0.00 |
| D1330 |
|
249 |
161 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
101 |
101 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
116 |
102 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
573 |
137 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
76 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
16 |
$0.00 |