| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
646 |
627 |
$28K |
| D8670 |
Periodic orthodontic treatment visit |
464 |
421 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
321 |
309 |
$14K |
| D2750 |
|
21 |
13 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
376 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
172 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
24 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
131 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
389 |
$2K |
| D0274 |
Bitewings - four radiographic images |
170 |
158 |
$2K |
| D1206 |
Topical application of fluoride varnish |
64 |
63 |
$885.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
256 |
181 |
$579.02 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$272.00 |
| D0350 |
|
81 |
80 |
$54.00 |
| D0431 |
|
223 |
211 |
$0.00 |
| D1999 |
|
14 |
14 |
$0.00 |