| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
76 |
76 |
$0.00 |
| D1351 |
Sealant - per tooth |
199 |
49 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
23 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
17 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
243 |
243 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
17 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
199 |
199 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
225 |
225 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$0.00 |
| D1120 |
Prophylaxis - child |
230 |
230 |
$0.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
60 |
$0.00 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$0.00 |