| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
242 |
229 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
56 |
54 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
567 |
528 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
640 |
355 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
171 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
447 |
406 |
$5K |
| D1351 |
Sealant - per tooth |
174 |
27 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
129 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$847.68 |
| D1110 |
Prophylaxis - adult |
16 |
12 |
$658.56 |
| D0603 |
|
795 |
729 |
$0.00 |