| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
168 |
165 |
$21K |
| D1120 |
Prophylaxis - child |
456 |
435 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,979 |
803 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
434 |
$12K |
| D1351 |
Sealant - per tooth |
512 |
97 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
774 |
732 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
875 |
825 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
131 |
$4K |
| D0274 |
Bitewings - four radiographic images |
145 |
138 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
159 |
155 |
$3K |
| D1110 |
Prophylaxis - adult |
29 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
24 |
$582.56 |
| D0603 |
|
1,452 |
1,377 |
$0.05 |