| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
45 |
45 |
$6K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
120 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
128 |
128 |
$4K |
| D1206 |
Topical application of fluoride varnish |
112 |
112 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
130 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$960.16 |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$937.87 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$420.84 |
| D0350 |
|
14 |
14 |
$257.32 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$235.20 |
| D0603 |
|
204 |
204 |
$0.00 |