| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
287 |
284 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,211 |
1,183 |
$32K |
| D1120 |
Prophylaxis - child |
753 |
740 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,371 |
1,477 |
$21K |
| D1110 |
Prophylaxis - adult |
435 |
422 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
105 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,463 |
1,434 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,634 |
1,568 |
$16K |
| D0274 |
Bitewings - four radiographic images |
479 |
465 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
61 |
$12K |
| D0272 |
Bitewings - two radiographic images |
435 |
425 |
$9K |
| D1351 |
Sealant - per tooth |
172 |
33 |
$4K |
| D0330 |
Panoramic radiographic image |
161 |
157 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
81 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
22 |
$1K |
| D0270 |
|
14 |
13 |
$34.30 |
| D0603 |
|
594 |
585 |
$9.02 |
| D0601 |
|
1,035 |
1,010 |
$0.00 |
| D0602 |
|
59 |
59 |
$0.00 |