| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
173 |
28 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$918.75 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$837.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
25 |
$817.21 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$750.10 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$565.12 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$351.68 |
| D0603 |
|
143 |
142 |
$0.00 |