| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
120 |
41 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
206 |
206 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
94 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
519 |
519 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
431 |
431 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
132 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
224 |
224 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
64 |
36 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
207 |
192 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
52 |
$0.00 |
| D1120 |
Prophylaxis - child |
363 |
363 |
$0.00 |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
20 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$0.00 |