| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,878 |
1,626 |
$103K |
| D1206 |
Topical application of fluoride varnish |
2,131 |
1,813 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,795 |
1,484 |
$64K |
| 99211 |
Office or other outpatient visit for the evaluation and management of an established patient, minimal severity |
2,108 |
1,875 |
$24K |
| D1351 |
Sealant - per tooth |
148 |
70 |
$10K |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
325 |
321 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
81 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
172 |
136 |
$3K |
| 90686 |
|
226 |
195 |
$2K |
| 90619 |
|
100 |
94 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
59 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
40 |
$1K |
| 90670 |
|
152 |
150 |
$972.80 |
| 90633 |
|
80 |
73 |
$944.89 |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
59 |
$845.52 |
| D0272 |
Bitewings - two radiographic images |
84 |
64 |
$686.20 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$625.92 |
| 90734 |
|
74 |
73 |
$473.60 |
| 92551 |
|
28 |
27 |
$420.60 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$408.86 |
| 90723 |
|
56 |
54 |
$358.40 |
| 90715 |
|
29 |
29 |
$345.41 |
| 90647 |
|
42 |
41 |
$268.80 |
| 90661 |
|
13 |
13 |
$217.23 |
| 99173 |
|
28 |
27 |
$206.15 |
| 36416 |
|
45 |
43 |
$184.50 |
| 90651 |
|
14 |
14 |
$89.60 |
| 90685 |
|
12 |
12 |
$76.80 |
| 85018 |
|
12 |
12 |
$27.84 |
| D0601 |
|
53 |
53 |
$0.00 |