| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$0.00 |
| D1330 |
|
46 |
46 |
$0.00 |
| D1310 |
|
51 |
50 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
251 |
47 |
$0.00 |
| D1351 |
Sealant - per tooth |
45 |
15 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$0.00 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$0.00 |