| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
20 |
20 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
30 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$0.00 |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
19 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
14 |
$0.00 |