| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
330 |
329 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,846 |
468 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
390 |
384 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
178 |
$5K |
| D1120 |
Prophylaxis - child |
143 |
142 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
522 |
507 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
65 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
98 |
96 |
$1K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$612.49 |
| D0350 |
|
43 |
43 |
$527.60 |
| D0603 |
|
1,239 |
1,221 |
$0.01 |
| D1999 |
|
432 |
415 |
$0.00 |