| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$346.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$176.40 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
13 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
22 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
18 |
$0.00 |