| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
105 |
101 |
$29.00 |
| D9248 |
|
13 |
13 |
$28.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
105 |
$10.00 |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
132 |
$10.00 |
| D0120 |
Periodic oral evaluation - established patient |
358 |
357 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
469 |
468 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
174 |
167 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
156 |
155 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
26 |
$0.00 |
| D7240 |
Removal of impacted tooth - completely bony |
29 |
13 |
$0.00 |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$0.00 |
| D1120 |
Prophylaxis - child |
386 |
385 |
$0.00 |
| D0330 |
Panoramic radiographic image |
152 |
145 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$0.00 |