| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,196 |
4,184 |
$120K |
| D0145 |
Oral evaluation for a patient under three years of age |
733 |
732 |
$104K |
| D1110 |
Prophylaxis - adult |
1,875 |
1,868 |
$101K |
| D1120 |
Prophylaxis - child |
2,493 |
2,486 |
$91K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,910 |
4,096 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
721 |
436 |
$73K |
| D0274 |
Bitewings - four radiographic images |
1,992 |
1,986 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,323 |
4,309 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
4,251 |
4,219 |
$53K |
| D1351 |
Sealant - per tooth |
1,558 |
406 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,297 |
1,296 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
170 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$777.04 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0601 |
|
635 |
634 |
$0.00 |
| D0603 |
|
678 |
677 |
$0.00 |
| D0602 |
|
3,658 |
3,648 |
$0.00 |