| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
250 |
244 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,072 |
1,046 |
$29K |
| D1120 |
Prophylaxis - child |
618 |
604 |
$22K |
| D1110 |
Prophylaxis - adult |
347 |
336 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,169 |
1,149 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,185 |
992 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,071 |
1,045 |
$13K |
| D0272 |
Bitewings - two radiographic images |
406 |
398 |
$9K |
| D0274 |
Bitewings - four radiographic images |
228 |
223 |
$8K |
| D1330 |
|
232 |
218 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$418.52 |
| D0601 |
|
1,287 |
1,262 |
$0.01 |
| D0603 |
|
193 |
191 |
$0.00 |