| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
24 |
$1K |
| D1120 |
Prophylaxis - child |
37 |
32 |
$183.75 |
| D0120 |
Periodic oral evaluation - established patient |
44 |
39 |
$144.25 |
| D0274 |
Bitewings - four radiographic images |
28 |
25 |
$138.44 |
| D1351 |
Sealant - per tooth |
82 |
12 |
$112.96 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$105.96 |
| D1206 |
Topical application of fluoride varnish |
51 |
45 |
$88.20 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
46 |
$87.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
43 |
$68.55 |
| D1110 |
Prophylaxis - adult |
19 |
18 |
$54.88 |
| D0272 |
Bitewings - two radiographic images |
15 |
13 |
$46.76 |
| D0603 |
|
92 |
76 |
$0.00 |