| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
169 |
89 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
17 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
21 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
32 |
$0.00 |
| D1351 |
Sealant - per tooth |
80 |
16 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
543 |
114 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
68 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
96 |
50 |
$0.00 |
| D0330 |
Panoramic radiographic image |
131 |
67 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
122 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
37 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
675 |
322 |
$0.00 |
| D1120 |
Prophylaxis - child |
113 |
59 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
151 |
77 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
13 |
$0.00 |
| D4341 |
|
75 |
31 |
$0.00 |