| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
828 |
198 |
$200.00 |
| D1120 |
Prophylaxis - child |
654 |
654 |
$0.00 |
| D1110 |
Prophylaxis - adult |
945 |
945 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
144 |
$0.00 |
| D0191 |
|
14 |
14 |
$0.00 |
| D1330 |
|
975 |
975 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
153 |
153 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
525 |
525 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
518 |
518 |
$0.00 |
| D1310 |
|
319 |
319 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
83 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$0.00 |