| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,586 |
1,586 |
$40K |
| D1120 |
Prophylaxis - child |
1,095 |
1,095 |
$35K |
| D1110 |
Prophylaxis - adult |
1,021 |
1,021 |
$33K |
| D1351 |
Sealant - per tooth |
1,647 |
220 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,273 |
1,265 |
$24K |
| D0330 |
Panoramic radiographic image |
750 |
750 |
$23K |
| D0251 |
|
1,325 |
1,325 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
575 |
575 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
129 |
53 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
483 |
483 |
$4K |
| D0603 |
|
342 |
342 |
$3K |
| D0602 |
|
176 |
176 |
$2K |
| D9920 |
|
29 |
29 |
$960.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
14 |
$895.00 |
| D0601 |
|
80 |
80 |
$800.00 |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$795.00 |
| D4346 |
|
14 |
14 |
$336.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$223.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$65.00 |
| D0190 |
|
72 |
64 |
$0.00 |