| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1310 |
|
240 |
240 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,748 |
1,745 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
830 |
829 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
465 |
$0.00 |
| D1351 |
Sealant - per tooth |
844 |
178 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
214 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
441 |
441 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,316 |
1,316 |
$0.00 |
| D1330 |
|
299 |
299 |
$0.00 |
| D1353 |
|
96 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
710 |
710 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,202 |
1,201 |
$0.00 |
| D0330 |
Panoramic radiographic image |
174 |
174 |
$0.00 |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
690 |
591 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
292 |
292 |
$0.00 |