| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
19 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
67 |
35 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
96 |
53 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
18 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
31 |
$0.00 |
| D1120 |
Prophylaxis - child |
88 |
51 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
26 |
$0.00 |
| D1110 |
Prophylaxis - adult |
25 |
12 |
$0.00 |