| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
166 |
165 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
545 |
541 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
13 |
$0.00 |
| D1351 |
Sealant - per tooth |
190 |
58 |
$0.00 |
| D0602 |
|
31 |
31 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
78 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
263 |
263 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
42 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
69 |
66 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$0.00 |
| D1120 |
Prophylaxis - child |
560 |
556 |
$0.00 |
| D0191 |
|
41 |
41 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$0.00 |