| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
67 |
67 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
514 |
218 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
144 |
$4K |
| D1120 |
Prophylaxis - child |
108 |
104 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
244 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
215 |
208 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
59 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
37 |
$1K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$987.84 |
| D0602 |
|
36 |
36 |
$0.00 |
| D0603 |
|
181 |
174 |
$0.00 |