| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
60 |
60 |
$7K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$6K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
15 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$3K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
13 |
$747.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$560.31 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$186.77 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$186.77 |
| D1330 |
|
32 |
32 |
$0.00 |
| D0191 |
|
30 |
30 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$0.00 |