| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
416 |
304 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
301 |
$10K |
| D1120 |
Prophylaxis - child |
432 |
343 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
323 |
$4K |
| D1206 |
Topical application of fluoride varnish |
186 |
154 |
$4K |
| D0274 |
Bitewings - four radiographic images |
104 |
92 |
$2K |
| D1351 |
Sealant - per tooth |
102 |
18 |
$2K |
| D0330 |
Panoramic radiographic image |
21 |
18 |
$886.82 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
12 |
$754.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
47 |
$706.24 |
| D0272 |
Bitewings - two radiographic images |
28 |
25 |
$478.67 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
15 |
$429.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
28 |
$419.04 |