| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
111 |
54 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
302 |
168 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
244 |
139 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
20 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
114 |
28 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
55 |
$0.00 |
| D1351 |
Sealant - per tooth |
38 |
12 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
43 |
24 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
20 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
67 |
41 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
21 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
53 |
$0.00 |
| D1120 |
Prophylaxis - child |
283 |
156 |
$0.00 |
| D1999 |
|
534 |
288 |
$0.00 |
| D0330 |
Panoramic radiographic image |
35 |
15 |
$0.00 |