| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
33 |
16 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
21 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$925.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$764.40 |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$611.84 |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
84 |
$548.63 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$547.68 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$514.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
66 |
$421.12 |
| D0270 |
|
24 |
24 |
$134.40 |