| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
108 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
402 |
367 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
56 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
52 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
152 |
120 |
$893.06 |
| D0272 |
Bitewings - two radiographic images |
46 |
44 |
$717.92 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
43 |
$543.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$519.16 |
| D1206 |
Topical application of fluoride varnish |
20 |
19 |
$248.43 |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$193.00 |
| D0603 |
|
192 |
180 |
$0.00 |
| D0601 |
|
198 |
183 |
$0.00 |