| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
514 |
74 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
254 |
251 |
$6K |
| D0274 |
Bitewings - four radiographic images |
290 |
283 |
$6K |
| D1206 |
Topical application of fluoride varnish |
366 |
357 |
$6K |
| D1120 |
Prophylaxis - child |
167 |
158 |
$5K |
| D1110 |
Prophylaxis - adult |
112 |
112 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
530 |
510 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
165 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
578 |
460 |
$4K |
| D4355 |
|
13 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
58 |
$698.71 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$232.87 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$224.88 |
| D4346 |
|
16 |
15 |
$0.00 |