| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
644 |
635 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
3,208 |
3,095 |
$86K |
| D1110 |
Prophylaxis - adult |
1,609 |
1,543 |
$81K |
| D1351 |
Sealant - per tooth |
2,870 |
600 |
$73K |
| D1120 |
Prophylaxis - child |
2,078 |
2,034 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,699 |
1,643 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,108 |
3,050 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
554 |
298 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,581 |
3,478 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
3,364 |
3,243 |
$40K |
| D0272 |
Bitewings - two radiographic images |
981 |
957 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
230 |
128 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
509 |
467 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
107 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0603 |
|
4,441 |
4,332 |
$0.00 |
| D0602 |
|
49 |
49 |
$0.00 |