| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
411 |
411 |
$17K |
| D1206 |
Topical application of fluoride varnish |
405 |
405 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
414 |
414 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
327 |
327 |
$9K |
| D0272 |
Bitewings - two radiographic images |
527 |
527 |
$5K |
| D1354 |
|
202 |
147 |
$5K |
| D1351 |
Sealant - per tooth |
48 |
35 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
553 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
90 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
536 |
533 |
$2K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$1K |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$261.84 |