| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
13 |
$0.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$0.00 |