| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$4K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
112 |
$3K |
| D1351 |
Sealant - per tooth |
102 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
71 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
46 |
$722.31 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$444.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
41 |
$346.39 |