| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
174 |
174 |
$443.56 |
| D0120 |
Periodic oral evaluation - established patient |
248 |
248 |
$366.73 |
| D0274 |
Bitewings - four radiographic images |
168 |
168 |
$355.83 |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
215 |
$214.64 |
| D1206 |
Topical application of fluoride varnish |
245 |
245 |
$212.29 |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
243 |
$116.99 |
| D1120 |
Prophylaxis - child |
167 |
167 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
28 |
$0.00 |
| D2140 |
|
41 |
15 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$0.00 |