| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
106 |
106 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$4K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$967.59 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$765.48 |
| D1120 |
Prophylaxis - child |
119 |
119 |
$588.64 |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
167 |
$384.03 |
| D1351 |
Sealant - per tooth |
58 |
13 |
$257.13 |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
260 |
142 |
$0.00 |
| D1330 |
|
157 |
157 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
160 |
160 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |