| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
8,585 |
8,565 |
$750K |
| D9920 |
|
3,194 |
3,099 |
$424K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,449 |
6,415 |
$415K |
| D9410 |
|
13,571 |
12,952 |
$378K |
| D4355 |
|
3,369 |
3,347 |
$311K |
| D0120 |
Periodic oral evaluation - established patient |
3,467 |
3,463 |
$242K |
| D1206 |
Topical application of fluoride varnish |
10,730 |
10,643 |
$179K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,325 |
6,906 |
$125K |
| D0220 |
Intraoral - periapical first radiographic image |
5,991 |
5,959 |
$72K |
| D5410 |
|
1,005 |
997 |
$35K |
| D9910 |
|
547 |
544 |
$27K |
| D5411 |
|
363 |
360 |
$12K |
| D1320 |
|
602 |
599 |
$10K |
| D0330 |
Panoramic radiographic image |
148 |
148 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
12 |
$4K |
| D2940 |
|
53 |
14 |
$3K |
| D4341 |
|
34 |
14 |
$3K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
51 |
$2K |
| D4910 |
|
13 |
13 |
$924.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$682.50 |
| D0350 |
|
40 |
14 |
$345.60 |