| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2331 |
|
17 |
15 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
247 |
231 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
23 |
21 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
346 |
274 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
182 |
165 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
109 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
31 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
292 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
241 |
230 |
$0.00 |
| D0330 |
Panoramic radiographic image |
171 |
165 |
$0.00 |
| D1110 |
Prophylaxis - adult |
123 |
117 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
69 |
44 |
$0.00 |
| D2140 |
|
33 |
17 |
$0.00 |
| D1120 |
Prophylaxis - child |
40 |
38 |
$0.00 |