| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
75 |
$5K |
| D1120 |
Prophylaxis - child |
595 |
329 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
633 |
349 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,405 |
491 |
$4K |
| D1110 |
Prophylaxis - adult |
237 |
133 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
169 |
$3K |
| D0274 |
Bitewings - four radiographic images |
335 |
180 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
898 |
498 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
651 |
362 |
$2K |
| D0272 |
Bitewings - two radiographic images |
364 |
206 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
118 |
$815.85 |
| D0603 |
|
1,089 |
603 |
$0.00 |