| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
149 |
30 |
$3K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$2K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$814.50 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$296.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
33 |
$256.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$208.00 |
| D1999 |
|
125 |
124 |
$0.00 |