| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
76 |
38 |
$0.00 |
| D0330 |
Panoramic radiographic image |
109 |
55 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
145 |
73 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
98 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
559 |
265 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
28 |
$0.00 |
| D4341 |
|
46 |
21 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
64 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
472 |
97 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
161 |
82 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
83 |
41 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
14 |
$0.00 |