| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
117 |
117 |
$43.50 |
| D0220 |
Intraoral - periapical first radiographic image |
165 |
165 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$0.00 |
| D1120 |
Prophylaxis - child |
167 |
167 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
41 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
506 |
506 |
$0.00 |
| D1330 |
|
93 |
93 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
209 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$0.00 |