| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,322 |
2,320 |
$110K |
| D1120 |
Prophylaxis - child |
2,527 |
2,523 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,500 |
2,771 |
$60K |
| D0272 |
Bitewings - two radiographic images |
2,478 |
2,475 |
$28K |
| D1351 |
Sealant - per tooth |
1,240 |
269 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
411 |
411 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,041 |
2,039 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
111 |
$12K |
| D0350 |
|
1,226 |
516 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$6K |
| D1206 |
Topical application of fluoride varnish |
338 |
338 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
12 |
$2K |
| D9430 |
|
38 |
38 |
$1K |
| D9993 |
|
51 |
51 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D1310 |
|
51 |
51 |
$816.50 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$648.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$450.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$302.40 |
| D0602 |
|
49 |
49 |
$251.25 |