| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
796 |
791 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
1,253 |
1,237 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,500 |
1,460 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
888 |
878 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,713 |
1,630 |
$5K |
| D1120 |
Prophylaxis - child |
208 |
207 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
237 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
106 |
$2K |
| D1351 |
Sealant - per tooth |
165 |
30 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
53 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
12 |
$938.00 |
| D0191 |
|
38 |
38 |
$515.00 |
| D0274 |
Bitewings - four radiographic images |
54 |
53 |
$168.00 |
| D0190 |
|
106 |
104 |
$130.00 |
| D0601 |
|
28 |
28 |
$120.00 |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$106.25 |