| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
48 |
44 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
98 |
$4K |
| D1110 |
Prophylaxis - adult |
107 |
99 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
34 |
31 |
$1K |
| D1120 |
Prophylaxis - child |
77 |
72 |
$1K |
| D1351 |
Sealant - per tooth |
256 |
50 |
$495.31 |
| D1330 |
|
315 |
287 |
$162.14 |
| D0274 |
Bitewings - four radiographic images |
29 |
27 |
$95.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
287 |
$65.61 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$0.00 |