| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
742 |
701 |
$97K |
| D1351 |
Sealant - per tooth |
3,054 |
376 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,565 |
2,353 |
$63K |
| D1110 |
Prophylaxis - adult |
1,222 |
1,152 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,696 |
1,599 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,701 |
1,594 |
$45K |
| D1120 |
Prophylaxis - child |
1,249 |
1,179 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,488 |
2,344 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,585 |
2,437 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
689 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
145 |
137 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
12 |
$3K |
| D0603 |
|
3,468 |
3,272 |
$0.00 |