| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
105 |
105 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
85 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
162 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
173 |
$0.00 |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$0.00 |
| D1120 |
Prophylaxis - child |
69 |
69 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$0.00 |
| D1110 |
Prophylaxis - adult |
21 |
21 |
$0.00 |