| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
274 |
274 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
351 |
349 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
94 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
73 |
72 |
$0.00 |
| D1351 |
Sealant - per tooth |
76 |
33 |
$0.00 |
| D0603 |
|
133 |
132 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
32 |
$0.00 |
| D1120 |
Prophylaxis - child |
328 |
327 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
321 |
296 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
20 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
114 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
73 |
$0.00 |