| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,089 |
2,089 |
$135K |
| D1110 |
Prophylaxis - adult |
1,491 |
1,489 |
$131K |
| D9410 |
|
3,789 |
3,740 |
$104K |
| D9920 |
|
811 |
807 |
$65K |
| D4355 |
|
411 |
411 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
1,083 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
443 |
162 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
520 |
520 |
$24K |
| D1206 |
Topical application of fluoride varnish |
814 |
814 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
851 |
849 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
908 |
464 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
492 |
490 |
$6K |
| D9110 |
|
12 |
12 |
$693.00 |
| D0170 |
|
27 |
27 |
$525.00 |
| D4341 |
|
38 |
12 |
$0.00 |