| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
97 |
95 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
43 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
38 |
$0.00 |
| D1110 |
Prophylaxis - adult |
48 |
48 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
28 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
133 |
132 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
137 |
135 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
24 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
21 |
21 |
$0.00 |