| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
914 |
879 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
348 |
336 |
$18K |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
929 |
480 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
871 |
842 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
503 |
489 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
199 |
113 |
$10K |
| D0274 |
Bitewings - four radiographic images |
524 |
505 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
631 |
616 |
$9K |
| D1120 |
Prophylaxis - child |
392 |
387 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
379 |
364 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
29 |
$2K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
69 |
62 |
$1K |
| D1351 |
Sealant - per tooth |
53 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
95 |
94 |
$930.00 |
| D2140 |
|
24 |
12 |
$880.00 |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
175 |
$784.00 |
| 90651 |
|
122 |
120 |
$694.80 |
| 90715 |
|
72 |
65 |
$424.75 |
| 90688 |
|
70 |
65 |
$261.34 |
| 92551 |
|
36 |
33 |
$194.48 |
| 90686 |
|
32 |
31 |
$185.07 |
| 90620 |
|
47 |
47 |
$181.20 |
| 96110 |
Developmental screening, with scoring and documentation, per standardized instrument |
13 |
12 |
$96.24 |
| G0008 |
Administration of influenza virus vaccine |
16 |
13 |
$24.03 |
| 90734 |
|
110 |
106 |
$10.00 |
| D9995 |
|
13 |
13 |
$0.00 |
| 90633 |
|
79 |
76 |
$0.00 |