| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
203 |
201 |
$0.00 |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$0.00 |
| D4910 |
|
48 |
45 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,158 |
1,144 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
109 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
39 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
157 |
156 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$0.00 |
| D9920 |
|
13 |
13 |
$0.00 |