| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
475 |
475 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
890 |
889 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,910 |
1,907 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,230 |
1,230 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
939 |
925 |
$0.00 |
| D9248 |
|
55 |
55 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
161 |
98 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
111 |
108 |
$0.00 |
| D1351 |
Sealant - per tooth |
1,317 |
365 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,476 |
1,476 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,063 |
1,060 |
$0.00 |
| D1110 |
Prophylaxis - adult |
401 |
401 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
172 |
172 |
$0.00 |
| D1354 |
|
196 |
76 |
$0.00 |
| D0350 |
|
664 |
661 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
605 |
605 |
$0.00 |
| D0330 |
Panoramic radiographic image |
201 |
201 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
28 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$0.00 |