| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
115 |
103 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,640 |
602 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
514 |
432 |
$12K |
| D1120 |
Prophylaxis - child |
349 |
296 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
709 |
600 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
763 |
634 |
$8K |
| D1351 |
Sealant - per tooth |
154 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
28 |
24 |
$728.59 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$303.94 |
| D0603 |
|
948 |
835 |
$0.00 |
| D0602 |
|
68 |
50 |
$0.00 |
| D1999 |
|
12 |
12 |
$0.00 |