| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
465 |
461 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,372 |
1,347 |
$38K |
| D1120 |
Prophylaxis - child |
936 |
925 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,595 |
1,227 |
$28K |
| D1110 |
Prophylaxis - adult |
448 |
440 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,547 |
1,527 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,288 |
1,258 |
$15K |
| D0272 |
Bitewings - two radiographic images |
603 |
592 |
$14K |
| D1351 |
Sealant - per tooth |
410 |
96 |
$11K |
| D0274 |
Bitewings - four radiographic images |
326 |
321 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
42 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
45 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$2K |
| D0603 |
|
2,438 |
2,382 |
$0.00 |