| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
1,636 |
1,427 |
$198K |
| D1351 |
Sealant - per tooth |
5,358 |
1,074 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
5,064 |
4,418 |
$123K |
| D1120 |
Prophylaxis - child |
3,654 |
3,137 |
$110K |
| D1110 |
Prophylaxis - adult |
1,889 |
1,690 |
$89K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,724 |
4,996 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,350 |
2,087 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
830 |
535 |
$66K |
| D0272 |
Bitewings - two radiographic images |
2,468 |
2,159 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
4,127 |
3,698 |
$45K |
| D0330 |
Panoramic radiographic image |
1,222 |
1,095 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,824 |
3,374 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
492 |
261 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
455 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
54 |
$1K |
| D0603 |
|
4,957 |
4,523 |
$0.00 |
| D0601 |
|
2,018 |
1,652 |
$0.00 |
| D0602 |
|
216 |
125 |
$0.00 |