| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
278 |
177 |
$12.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
100 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
127 |
125 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
29 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
146 |
144 |
$0.00 |
| D0603 |
|
88 |
88 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$0.00 |
| D1110 |
Prophylaxis - adult |
76 |
75 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$0.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$0.00 |