| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
986 |
985 |
$0.00 |
| D1110 |
Prophylaxis - adult |
464 |
464 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
691 |
691 |
$0.00 |
| D0330 |
Panoramic radiographic image |
212 |
206 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,473 |
1,473 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
29 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
140 |
135 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
110 |
110 |
$0.00 |
| D0350 |
|
617 |
609 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
890 |
884 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
668 |
668 |
$0.00 |
| D1351 |
Sealant - per tooth |
1,223 |
300 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,953 |
1,952 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,107 |
1,107 |
$0.00 |
| D1353 |
|
323 |
91 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
850 |
850 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
117 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$0.00 |
| D9248 |
|
13 |
13 |
$0.00 |