| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
538 |
538 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
73 |
$0.00 |
| D1110 |
Prophylaxis - adult |
303 |
303 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
176 |
168 |
$0.00 |
| D1351 |
Sealant - per tooth |
141 |
53 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
823 |
823 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
315 |
315 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
535 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
67 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
206 |
206 |
$0.00 |