| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
70 |
70 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
40 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
257 |
$7K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$7K |
| D1351 |
Sealant - per tooth |
243 |
71 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
275 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
354 |
264 |
$4K |
| D1110 |
Prophylaxis - adult |
68 |
68 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
269 |
269 |
$3K |
| D0272 |
Bitewings - two radiographic images |
137 |
137 |
$3K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$3K |
| D0603 |
|
369 |
369 |
$0.00 |