| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
46 |
$180.00 |
| D9430 |
|
183 |
169 |
$100.00 |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
223 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$0.00 |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$0.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
145 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
228 |
226 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
154 |
154 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
31 |
$0.00 |