| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
761 |
73 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
132 |
$8K |
| D1206 |
Topical application of fluoride varnish |
207 |
176 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
395 |
360 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
229 |
$7K |
| D0274 |
Bitewings - four radiographic images |
285 |
251 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
339 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
546 |
357 |
$3K |
| D1120 |
Prophylaxis - child |
49 |
47 |
$2K |
| D0330 |
Panoramic radiographic image |
50 |
48 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
42 |
$1K |
| D4346 |
|
13 |
13 |
$689.00 |