| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
25 |
$852.42 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$103.83 |
| D0120 |
Periodic oral evaluation - established patient |
74 |
74 |
$86.55 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$54.88 |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$44.10 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
70 |
$37.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
68 |
$34.53 |
| D1120 |
Prophylaxis - child |
39 |
39 |
$0.00 |
| D0603 |
|
109 |
107 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
19 |
$0.00 |