| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
940 |
939 |
$50.00 |
| D1120 |
Prophylaxis - child |
306 |
306 |
$40.85 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
75 |
$26.60 |
| D0272 |
Bitewings - two radiographic images |
101 |
101 |
$16.15 |
| D0120 |
Periodic oral evaluation - established patient |
611 |
611 |
$12.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
452 |
451 |
$8.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
301 |
301 |
$0.00 |
| D1330 |
|
219 |
219 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$0.00 |
| D1310 |
|
52 |
52 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$0.00 |
| D1351 |
Sealant - per tooth |
520 |
111 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
183 |
183 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
24 |
$0.00 |