| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
283 |
283 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
687 |
686 |
$0.00 |
| D1120 |
Prophylaxis - child |
612 |
611 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
66 |
$0.00 |
| D1110 |
Prophylaxis - adult |
183 |
183 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
60 |
$0.00 |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
248 |
248 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
92 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
702 |
679 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
650 |
649 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
750 |
748 |
$0.00 |
| D1351 |
Sealant - per tooth |
61 |
26 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
57 |
57 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$0.00 |