| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
83 |
69 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$0.00 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$0.00 |
| D0330 |
Panoramic radiographic image |
52 |
45 |
$0.00 |
| D1120 |
Prophylaxis - child |
170 |
149 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
14 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
225 |
201 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
198 |
177 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
108 |
87 |
$0.00 |
| D1351 |
Sealant - per tooth |
119 |
29 |
$0.00 |