| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
537 |
145 |
$11K |
| D1206 |
Topical application of fluoride varnish |
479 |
468 |
$7K |
| D1120 |
Prophylaxis - child |
319 |
308 |
$6K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
248 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
68 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
70 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$980.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
16 |
$350.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
36 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
38 |
$190.00 |