| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
399 |
393 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,466 |
1,457 |
$42K |
| D1120 |
Prophylaxis - child |
1,104 |
1,094 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,714 |
1,539 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,680 |
1,669 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
99 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,637 |
1,620 |
$20K |
| D1110 |
Prophylaxis - adult |
178 |
178 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
56 |
$9K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$8K |
| D1351 |
Sealant - per tooth |
292 |
75 |
$8K |
| D0272 |
Bitewings - two radiographic images |
294 |
293 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$883.00 |
| D1330 |
|
68 |
68 |
$171.50 |
| D0350 |
|
13 |
13 |
$110.28 |
| D0603 |
|
774 |
769 |
$0.00 |
| D0601 |
|
829 |
817 |
$0.00 |
| D0602 |
|
270 |
270 |
$0.00 |