| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
28 |
$4K |
| D1351 |
Sealant - per tooth |
140 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$551.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$529.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
34 |
$470.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
34 |
$276.24 |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
34 |
$175.84 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$63.78 |
| D0603 |
|
13 |
13 |
$0.00 |
| D0602 |
|
13 |
12 |
$0.00 |
| D0601 |
|
25 |
25 |
$0.00 |