| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
31 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
43 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
162 |
142 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
83 |
74 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
177 |
$0.00 |
| D1351 |
Sealant - per tooth |
61 |
17 |
$0.00 |
| D1120 |
Prophylaxis - child |
157 |
141 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
15 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
72 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
13 |
$0.00 |
| D0330 |
Panoramic radiographic image |
40 |
35 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
21 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$0.00 |