| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,043 |
1,043 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
263 |
263 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
171 |
170 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
102 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,409 |
1,402 |
$0.00 |
| D1110 |
Prophylaxis - adult |
244 |
243 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
145 |
53 |
$0.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
809 |
806 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
182 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,340 |
1,336 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,228 |
1,226 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,245 |
1,244 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$0.00 |
| D0603 |
|
86 |
86 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$0.00 |
| D1351 |
Sealant - per tooth |
95 |
31 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
25 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |