| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
592 |
584 |
$81K |
| D1120 |
Prophylaxis - child |
1,942 |
1,837 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,482 |
1,392 |
$39K |
| D0272 |
Bitewings - two radiographic images |
1,465 |
1,386 |
$32K |
| D1351 |
Sealant - per tooth |
915 |
203 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,392 |
1,315 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
526 |
509 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
922 |
863 |
$11K |
| D1206 |
Topical application of fluoride varnish |
556 |
522 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
671 |
589 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$658.56 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$415.32 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$244.14 |
| D0603 |
|
2,787 |
2,691 |
$0.00 |