| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
155 |
108 |
$6K |
| D1206 |
Topical application of fluoride varnish |
156 |
110 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
88 |
$3K |
| D1351 |
Sealant - per tooth |
35 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
126 |
$968.80 |
| D0274 |
Bitewings - four radiographic images |
58 |
43 |
$946.40 |
| D0272 |
Bitewings - two radiographic images |
95 |
67 |
$883.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
167 |
121 |
$668.80 |
| D1110 |
Prophylaxis - adult |
16 |
12 |
$615.00 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
16 |
$372.60 |
| D1999 |
|
173 |
107 |
$0.00 |