| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
127 |
127 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
127 |
$0.00 |
| D1120 |
Prophylaxis - child |
42 |
42 |
$0.00 |
| D2950 |
|
36 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
46 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
37 |
13 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
102 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
16 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |
| D1351 |
Sealant - per tooth |
71 |
25 |
$0.00 |