| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$4K |
| D1351 |
Sealant - per tooth |
112 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
72 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
51 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
140 |
86 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
84 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
90 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D0272 |
Bitewings - two radiographic images |
28 |
27 |
$631.26 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$449.93 |
| D0601 |
|
16 |
16 |
$0.00 |
| D0603 |
|
69 |
67 |
$0.00 |