| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
167 |
76 |
$26K |
| D1120 |
Prophylaxis - child |
273 |
271 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
391 |
382 |
$11K |
| D1351 |
Sealant - per tooth |
108 |
57 |
$7K |
| D0274 |
Bitewings - four radiographic images |
335 |
330 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
204 |
$5K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
110 |
$3K |
| D1206 |
Topical application of fluoride varnish |
95 |
95 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
412 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
392 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$414.80 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$354.15 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$169.04 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$166.35 |