| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
308 |
44 |
$6K |
| D1120 |
Prophylaxis - child |
139 |
130 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
438 |
138 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
241 |
219 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
86 |
80 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
146 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
50 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
14 |
$777.32 |
| D0350 |
|
58 |
45 |
$496.26 |
| D0274 |
Bitewings - four radiographic images |
15 |
14 |
$484.54 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$191.10 |
| D0602 |
|
216 |
196 |
$0.00 |
| D0603 |
|
31 |
26 |
$0.00 |