| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
188 |
$0.00 |
| D1110 |
Prophylaxis - adult |
1,287 |
1,287 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,452 |
1,448 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
770 |
770 |
$0.00 |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
128 |
128 |
$0.00 |
| D0340 |
|
104 |
104 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,678 |
1,678 |
$0.00 |
| D8660 |
|
99 |
99 |
$0.00 |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$0.00 |
| D2940 |
|
29 |
16 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
429 |
402 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
14 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
2,465 |
2,465 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
2,865 |
2,865 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
175 |
173 |
$0.00 |
| D1351 |
Sealant - per tooth |
523 |
158 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,123 |
1,162 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
475 |
475 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
600 |
600 |
$0.00 |
| D9630 |
|
1,016 |
1,016 |
$0.00 |
| D7240 |
Removal of impacted tooth - completely bony |
166 |
54 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
448 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
163 |
$0.00 |
| D0240 |
|
108 |
60 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
14 |
$0.00 |