| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,540 |
2,539 |
$71K |
| D0251 |
|
2,418 |
2,418 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,975 |
2,975 |
$59K |
| D1351 |
Sealant - per tooth |
3,011 |
748 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,277 |
2,277 |
$45K |
| D1354 |
|
965 |
351 |
$19K |
| D9920 |
|
510 |
483 |
$15K |
| D0603 |
|
1,185 |
1,185 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
529 |
529 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
51 |
$6K |
| D1110 |
Prophylaxis - adult |
152 |
152 |
$5K |
| D0272 |
Bitewings - two radiographic images |
339 |
339 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
492 |
489 |
$5K |
| D0250 |
|
439 |
439 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
440 |
440 |
$4K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
25 |
$3K |
| D1353 |
|
126 |
27 |
$1K |
| D2140 |
|
16 |
13 |
$854.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$754.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$300.00 |
| D0601 |
|
13 |
13 |
$130.00 |
| D0602 |
|
12 |
12 |
$120.00 |