| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$0.00 |
| D1120 |
Prophylaxis - child |
21 |
21 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
126 |
$0.00 |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
109 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
86 |
86 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$0.00 |