| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
77 |
73 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
82 |
78 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
18 |
15 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$0.00 |
| D1110 |
Prophylaxis - adult |
54 |
51 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$0.00 |
| D1120 |
Prophylaxis - child |
46 |
45 |
$0.00 |