| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
336 |
319 |
$11K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
374 |
316 |
$9K |
| D1351 |
Sealant - per tooth |
368 |
47 |
$9K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
189 |
162 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
349 |
317 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
165 |
$5K |
| D0274 |
Bitewings - four radiographic images |
136 |
129 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
122 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
178 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
247 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
112 |
95 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$660.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
34 |
$493.00 |
| 99201 |
|
23 |
22 |
$486.78 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
30 |
26 |
$439.83 |