| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
112 |
112 |
$0.00 |
| D1120 |
Prophylaxis - child |
972 |
968 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
89 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
32 |
25 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
326 |
322 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
96 |
94 |
$0.00 |
| D0330 |
Panoramic radiographic image |
225 |
222 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
434 |
429 |
$0.00 |
| D1110 |
Prophylaxis - adult |
206 |
204 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,163 |
1,156 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
279 |
$0.00 |
| D1351 |
Sealant - per tooth |
289 |
81 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
242 |
239 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
792 |
291 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
625 |
623 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
805 |
803 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
74 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
211 |
$0.00 |