| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
61 |
27 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
104 |
54 |
$0.00 |
| D1120 |
Prophylaxis - child |
68 |
36 |
$0.00 |
| D0330 |
Panoramic radiographic image |
97 |
50 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
450 |
218 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
77 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
14 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
344 |
71 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
58 |
31 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
53 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
123 |
65 |
$0.00 |
| D4342 |
|
70 |
27 |
$0.00 |