| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
150 |
90 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
41 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
16 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
12 |
$0.00 |
| D1120 |
Prophylaxis - child |
49 |
31 |
$0.00 |
| D1110 |
Prophylaxis - adult |
66 |
30 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
92 |
51 |
$0.00 |