| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
482 |
449 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,078 |
908 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
549 |
518 |
$11K |
| D1351 |
Sealant - per tooth |
489 |
53 |
$11K |
| D1120 |
Prophylaxis - child |
200 |
192 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
140 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
13 |
$3K |
| D1353 |
|
120 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
64 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
30 |
$2K |
| D0603 |
|
107 |
100 |
$956.20 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
12 |
$749.98 |
| D0277 |
|
13 |
12 |
$405.40 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
24 |
$385.10 |
| D0602 |
|
30 |
30 |
$282.08 |
| D9630 |
|
26 |
25 |
$198.00 |
| D1330 |
|
286 |
270 |
$0.00 |
| D1310 |
|
286 |
271 |
$0.00 |