| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
983 |
976 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,017 |
1,008 |
$28K |
| D0145 |
Oral evaluation for a patient under three years of age |
164 |
163 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,175 |
1,166 |
$17K |
| D0272 |
Bitewings - two radiographic images |
604 |
595 |
$13K |
| D9248 |
|
28 |
27 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
74 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
116 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$988.96 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$455.63 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
36 |
$420.12 |
| D0601 |
|
110 |
110 |
$0.00 |
| D0603 |
|
134 |
134 |
$0.00 |
| D0602 |
|
1,045 |
1,038 |
$0.00 |