| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
19 |
$0.00 |
| D1110 |
Prophylaxis - adult |
131 |
106 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
54 |
49 |
$0.00 |
| D1120 |
Prophylaxis - child |
36 |
29 |
$0.00 |
| D0330 |
Panoramic radiographic image |
29 |
25 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
164 |
130 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
146 |
$0.00 |
| D1351 |
Sealant - per tooth |
129 |
33 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
21 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
18 |
15 |
$0.00 |