| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
575 |
563 |
$78K |
| D1351 |
Sealant - per tooth |
1,526 |
254 |
$34K |
| D1120 |
Prophylaxis - child |
913 |
849 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
901 |
835 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,845 |
970 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,042 |
951 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,088 |
1,003 |
$12K |
| D0272 |
Bitewings - two radiographic images |
233 |
210 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
12 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
118 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
18 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
24 |
$823.72 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$543.31 |
| D0603 |
|
1,022 |
955 |
$0.00 |
| D0602 |
|
732 |
704 |
$0.00 |