| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
134 |
85 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,145 |
660 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,452 |
855 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
277 |
182 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
131 |
35 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
498 |
286 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,231 |
727 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
135 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
161 |
79 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,432 |
844 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
72 |
$0.00 |
| D1351 |
Sealant - per tooth |
449 |
78 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,288 |
629 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
68 |
18 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
1,030 |
609 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
187 |
73 |
$0.00 |