| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
442 |
$0.00 |
| D1351 |
Sealant - per tooth |
36 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
387 |
386 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
53 |
$0.00 |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
53 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
77 |
$0.00 |
| D1120 |
Prophylaxis - child |
445 |
444 |
$0.00 |