| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
191 |
58 |
$10K |
| D1120 |
Prophylaxis - child |
209 |
208 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
240 |
237 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
206 |
$5K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
172 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
151 |
$842.19 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$725.70 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$144.17 |
| D1999 |
|
168 |
161 |
$0.00 |