| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
37 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
16 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
34 |
$0.00 |
| D1110 |
Prophylaxis - adult |
22 |
21 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
35 |
$0.00 |
| D1120 |
Prophylaxis - child |
18 |
16 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
18 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
29 |
$0.00 |
| D0330 |
Panoramic radiographic image |
27 |
20 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
29 |
$0.00 |
| D2332 |
|
23 |
12 |
$0.00 |