| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,255 |
2,255 |
$72K |
| D1120 |
Prophylaxis - child |
1,749 |
1,749 |
$55K |
| D1110 |
Prophylaxis - adult |
558 |
558 |
$43K |
| D1351 |
Sealant - per tooth |
810 |
239 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,900 |
1,900 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,433 |
1,433 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
136 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
96 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,377 |
1,374 |
$6K |
| D0274 |
Bitewings - four radiographic images |
537 |
537 |
$4K |
| D1206 |
Topical application of fluoride varnish |
338 |
338 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,152 |
1,146 |
$3K |
| D9995 |
|
176 |
176 |
$3K |
| D1353 |
|
107 |
43 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$900.00 |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$753.60 |
| D0330 |
Panoramic radiographic image |
19 |
18 |
$315.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
62 |
61 |
$46.80 |
| D0240 |
|
166 |
166 |
$23.44 |
| D1330 |
|
1,383 |
1,383 |
$9.00 |
| D0603 |
|
130 |
130 |
$0.00 |
| D0602 |
|
67 |
67 |
$0.00 |
| D0601 |
|
34 |
34 |
$0.00 |