| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,109 |
1,095 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
4,220 |
4,160 |
$119K |
| D1120 |
Prophylaxis - child |
2,785 |
2,739 |
$99K |
| D1110 |
Prophylaxis - adult |
1,501 |
1,487 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
687 |
351 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,462 |
4,394 |
$64K |
| D0272 |
Bitewings - two radiographic images |
2,182 |
2,151 |
$49K |
| D1351 |
Sealant - per tooth |
1,801 |
408 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,359 |
1,340 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,216 |
2,185 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,720 |
2,607 |
$32K |
| D0240 |
|
2,945 |
1,456 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
126 |
$18K |
| D0330 |
Panoramic radiographic image |
64 |
61 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$515.68 |
| D1330 |
|
50 |
50 |
$12.25 |
| D0603 |
|
1,048 |
1,038 |
$0.00 |
| D0601 |
|
2,169 |
2,148 |
$0.00 |
| D0602 |
|
2,127 |
2,104 |
$0.00 |