| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
635 |
635 |
$16K |
| D1110 |
Prophylaxis - adult |
402 |
402 |
$13K |
| D1120 |
Prophylaxis - child |
346 |
346 |
$11K |
| D1206 |
Topical application of fluoride varnish |
405 |
405 |
$8K |
| D0330 |
Panoramic radiographic image |
217 |
217 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
53 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$5K |
| D0274 |
Bitewings - four radiographic images |
196 |
196 |
$3K |
| D0251 |
|
225 |
225 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
276 |
276 |
$2K |
| D1351 |
Sealant - per tooth |
81 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
177 |
176 |
$980.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$587.00 |
| D0601 |
|
15 |
15 |
$150.00 |
| D0603 |
|
14 |
14 |
$140.00 |