| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
292 |
287 |
$40K |
| D1120 |
Prophylaxis - child |
874 |
854 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,077 |
1,056 |
$30K |
| D1351 |
Sealant - per tooth |
1,075 |
204 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,906 |
1,193 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,271 |
1,245 |
$18K |
| D0272 |
Bitewings - two radiographic images |
751 |
738 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,297 |
1,261 |
$15K |
| D1110 |
Prophylaxis - adult |
117 |
116 |
$6K |
| D0274 |
Bitewings - four radiographic images |
177 |
168 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
16 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0603 |
|
1,773 |
1,736 |
$0.02 |
| D0601 |
|
12 |
12 |
$0.00 |