| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
100 |
76 |
$0.00 |
| D1120 |
Prophylaxis - child |
15 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
27 |
$0.00 |
| D1110 |
Prophylaxis - adult |
141 |
105 |
$0.00 |
| D0330 |
Panoramic radiographic image |
20 |
17 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
74 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
46 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
27 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
74 |
54 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
134 |
101 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
51 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
97 |
59 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
12 |
$0.00 |