| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0190 |
|
154 |
97 |
$0.00 |
| D1999 |
|
490 |
345 |
$0.00 |
| D1120 |
Prophylaxis - child |
173 |
86 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
81 |
40 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
3,810 |
1,350 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
892 |
434 |
$0.00 |
| D1110 |
Prophylaxis - adult |
262 |
136 |
$0.00 |
| D0270 |
|
356 |
177 |
$0.00 |
| D4341 |
|
291 |
60 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
71 |
$0.00 |
| D0191 |
|
74 |
37 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
438 |
219 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
541 |
175 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
667 |
330 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
631 |
309 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
468 |
232 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
620 |
201 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
754 |
377 |
$0.00 |
| D1351 |
Sealant - per tooth |
405 |
68 |
$0.00 |
| D1330 |
|
257 |
256 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
51 |
25 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
26 |
$0.00 |
| D0603 |
|
14 |
14 |
$0.00 |