| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$4K |
| D1120 |
Prophylaxis - child |
98 |
98 |
$4K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
161 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
68 |
$728.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
43 |
$529.46 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0603 |
|
212 |
202 |
$0.00 |