| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
544 |
77 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
146 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
223 |
$3K |
| D1120 |
Prophylaxis - child |
84 |
84 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$847.68 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$615.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
34 |
$379.83 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$353.20 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$173.05 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$140.28 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0603 |
|
292 |
292 |
$0.00 |