| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
730 |
719 |
$100K |
| D1120 |
Prophylaxis - child |
2,123 |
2,109 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,611 |
2,599 |
$74K |
| D1351 |
Sealant - per tooth |
2,666 |
486 |
$68K |
| D1206 |
Topical application of fluoride varnish |
2,621 |
2,605 |
$37K |
| D1110 |
Prophylaxis - adult |
687 |
685 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,228 |
1,936 |
$35K |
| D0274 |
Bitewings - four radiographic images |
821 |
818 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,036 |
2,007 |
$24K |
| D0272 |
Bitewings - two radiographic images |
731 |
723 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
59 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
249 |
$8K |
| D0330 |
Panoramic radiographic image |
162 |
157 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
76 |
74 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
110 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
12 |
$1K |
| D0603 |
|
1,088 |
1,077 |
$0.00 |
| D0602 |
|
2,599 |
2,584 |
$0.00 |