| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
210 |
143 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
175 |
$7K |
| D4341 |
|
48 |
25 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
137 |
$5K |
| D0274 |
Bitewings - four radiographic images |
236 |
158 |
$4K |
| D1351 |
Sealant - per tooth |
51 |
17 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
20 |
$4K |
| D9110 |
|
61 |
47 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
107 |
$3K |
| D4342 |
|
33 |
14 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
32 |
$3K |
| D0330 |
Panoramic radiographic image |
105 |
71 |
$2K |
| D1110 |
Prophylaxis - adult |
37 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
141 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
88 |
$1K |
| D0272 |
Bitewings - two radiographic images |
75 |
48 |
$686.20 |