| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
104 |
101 |
$7K |
| D1351 |
Sealant - per tooth |
221 |
25 |
$6K |
| D1120 |
Prophylaxis - child |
204 |
199 |
$6K |
| D1206 |
Topical application of fluoride varnish |
221 |
213 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
103 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
111 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
92 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$626.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
21 |
$290.43 |