| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,409 |
1,405 |
$60K |
| D9410 |
|
477 |
465 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,372 |
1,359 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
292 |
94 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
630 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
856 |
834 |
$10K |
| D0274 |
Bitewings - four radiographic images |
293 |
293 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
256 |
$8K |
| D1206 |
Topical application of fluoride varnish |
414 |
410 |
$7K |
| D4910 |
|
48 |
48 |
$4K |
| D0330 |
Panoramic radiographic image |
52 |
52 |
$3K |
| D4346 |
|
41 |
39 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$411.60 |
| D1354 |
|
44 |
13 |
$243.32 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$185.75 |