| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
139 |
112 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
67 |
49 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
35 |
32 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
35 |
$0.00 |
| D1351 |
Sealant - per tooth |
239 |
36 |
$0.00 |
| D1110 |
Prophylaxis - adult |
31 |
26 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
27 |
$0.00 |
| D1120 |
Prophylaxis - child |
67 |
48 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
15 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
154 |
117 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
14 |
$0.00 |