| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
318 |
318 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
534 |
534 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
45 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
32 |
32 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
261 |
$0.00 |
| D3120 |
|
23 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
108 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
27 |
$0.00 |
| D1351 |
Sealant - per tooth |
658 |
173 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
356 |
356 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$0.00 |
| D2330 |
|
27 |
17 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
200 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
15 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
255 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
82 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$0.00 |
| D1120 |
Prophylaxis - child |
500 |
500 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
131 |
131 |
$0.00 |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$0.00 |
| D1110 |
Prophylaxis - adult |
120 |
120 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
139 |
69 |
$0.00 |