| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,267 |
1,267 |
$36K |
| D1120 |
Prophylaxis - child |
915 |
915 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,203 |
1,203 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,435 |
1,260 |
$28K |
| D1351 |
Sealant - per tooth |
911 |
187 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,413 |
1,413 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
119 |
119 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,307 |
1,305 |
$16K |
| D1110 |
Prophylaxis - adult |
254 |
254 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0603 |
|
757 |
756 |
$0.00 |
| D0602 |
|
915 |
909 |
$0.00 |