| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
593 |
593 |
$0.00 |
| D9310 |
|
246 |
246 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
404 |
404 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
602 |
602 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
519 |
218 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
139 |
$0.00 |
| D1351 |
Sealant - per tooth |
86 |
38 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
14 |
$0.00 |
| D9248 |
|
48 |
48 |
$0.00 |
| D1120 |
Prophylaxis - child |
644 |
644 |
$0.00 |
| D1110 |
Prophylaxis - adult |
127 |
127 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
195 |
184 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
106 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
92 |
48 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
62 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$0.00 |