| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
72 |
70 |
$10K |
| D1351 |
Sealant - per tooth |
277 |
61 |
$7K |
| D1120 |
Prophylaxis - child |
184 |
184 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
428 |
212 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
174 |
171 |
$5K |
| D1206 |
Topical application of fluoride varnish |
269 |
265 |
$4K |
| D1110 |
Prophylaxis - adult |
67 |
63 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
224 |
$3K |
| D0274 |
Bitewings - four radiographic images |
77 |
74 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
33 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
68 |
$2K |
| D0603 |
|
145 |
143 |
$0.00 |
| D0601 |
|
142 |
139 |
$0.00 |
| D0602 |
|
34 |
34 |
$0.00 |