| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
291 |
289 |
$30.00 |
| D9248 |
|
14 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
112 |
112 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
583 |
204 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
88 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
104 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
125 |
125 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
40 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$0.00 |
| D1120 |
Prophylaxis - child |
202 |
202 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$0.00 |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
13 |
$0.00 |