| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
273 |
273 |
$25.00 |
| D1310 |
|
128 |
128 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
401 |
401 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
76 |
$0.00 |
| D1330 |
|
294 |
294 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
29 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
226 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
239 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
189 |
189 |
$0.00 |
| D1120 |
Prophylaxis - child |
56 |
56 |
$0.00 |