| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
387 |
386 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$19K |
| D1110 |
Prophylaxis - adult |
166 |
166 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
124 |
$5K |
| D0191 |
|
223 |
223 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
567 |
565 |
$2K |
| D1351 |
Sealant - per tooth |
307 |
77 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$673.26 |
| D1120 |
Prophylaxis - child |
387 |
384 |
$398.06 |
| D0272 |
Bitewings - two radiographic images |
167 |
166 |
$79.36 |
| D1330 |
|
717 |
714 |
$0.00 |
| D0601 |
|
208 |
207 |
$0.00 |
| D0603 |
|
18 |
18 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$0.00 |