| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
760 |
149 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
70 |
70 |
$5K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
30 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
197 |
196 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
31 |
$3K |
| D1110 |
Prophylaxis - adult |
90 |
90 |
$2K |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
230 |
230 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
266 |
266 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
255 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$2K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$544.60 |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$330.75 |
| D0603 |
|
341 |
341 |
$0.00 |