| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
212 |
169 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
213 |
$8K |
| D1120 |
Prophylaxis - child |
241 |
208 |
$5K |
| D1206 |
Topical application of fluoride varnish |
151 |
149 |
$4K |
| D1351 |
Sealant - per tooth |
109 |
16 |
$3K |
| D0330 |
Panoramic radiographic image |
104 |
99 |
$3K |
| D0272 |
Bitewings - two radiographic images |
113 |
85 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$795.84 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
43 |
$430.98 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$332.52 |