| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
979 |
979 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,458 |
1,458 |
$32K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
393 |
309 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
308 |
308 |
$12K |
| D1110 |
Prophylaxis - adult |
224 |
224 |
$11K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
182 |
155 |
$8K |
| D1351 |
Sealant - per tooth |
204 |
60 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
25 |
$6K |
| 0001A |
|
152 |
146 |
$6K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$5K |
| 0002A |
|
111 |
107 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
112 |
112 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$4K |
| D1354 |
|
359 |
100 |
$3K |
| D0272 |
Bitewings - two radiographic images |
96 |
96 |
$3K |
| 0012A |
|
91 |
86 |
$3K |
| 0011A |
|
112 |
98 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$2K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
72 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| 0071A |
|
23 |
23 |
$629.05 |
| 0064A |
|
19 |
18 |
$490.36 |
| 0031A |
|
14 |
14 |
$451.04 |
| 0072A |
|
14 |
14 |
$448.43 |
| 87426 |
Infectious agent antigen detection, SARS-CoV-2 (COVID-19) |
21 |
12 |
$236.78 |
| 99421 |
|
22 |
16 |
$175.87 |
| 91301 |
|
24 |
20 |
$0.00 |