| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
103 |
103 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
14 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
464 |
225 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
169 |
$5K |
| D1120 |
Prophylaxis - child |
103 |
101 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
229 |
$3K |
| D0274 |
Bitewings - four radiographic images |
96 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
239 |
$3K |
| D1351 |
Sealant - per tooth |
106 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0603 |
|
223 |
217 |
$0.00 |
| D0602 |
|
65 |
65 |
$0.00 |