| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,996 |
5,980 |
$190K |
| D0210 |
Intraoral - complete series of radiographic images |
2,623 |
2,618 |
$112K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,773 |
3,766 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
4,738 |
4,727 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,626 |
1,619 |
$30K |
| D5110 |
|
55 |
55 |
$19K |
| D0274 |
Bitewings - four radiographic images |
777 |
777 |
$18K |
| D1120 |
Prophylaxis - child |
579 |
575 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
383 |
149 |
$10K |
| D5120 |
|
15 |
15 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
253 |
253 |
$4K |
| D1351 |
Sealant - per tooth |
131 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
327 |
$2K |
| D2140 |
|
17 |
13 |
$826.94 |
| D2332 |
|
15 |
12 |
$813.28 |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$721.99 |
| D2331 |
|
16 |
12 |
$703.97 |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
71 |
$590.21 |
| D4355 |
|
13 |
13 |
$519.12 |
| D5411 |
|
12 |
12 |
$441.00 |