| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
117 |
117 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$0.00 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$0.00 |
| D0350 |
|
84 |
84 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
107 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$0.00 |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
180 |
179 |
$0.00 |
| D1351 |
Sealant - per tooth |
73 |
25 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
96 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
104 |
104 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$0.00 |