| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
668 |
659 |
$50K |
| D4341 |
|
280 |
88 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
408 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
278 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,757 |
556 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
277 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
260 |
258 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
25 |
$3K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D4910 |
|
14 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$970.00 |
| D9110 |
|
13 |
13 |
$819.00 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$684.00 |