| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
333 |
303 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
452 |
422 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
45 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
270 |
267 |
$0.00 |
| D1330 |
|
142 |
105 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
377 |
354 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
612 |
334 |
$0.00 |
| D1351 |
Sealant - per tooth |
25 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
152 |
119 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
70 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
210 |
207 |
$0.00 |
| D0603 |
|
28 |
28 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
13 |
$0.00 |