| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
209 |
209 |
$9K |
| D1351 |
Sealant - per tooth |
99 |
57 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
219 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$5K |
| D4341 |
|
23 |
14 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$4K |
| D0274 |
Bitewings - four radiographic images |
179 |
176 |
$3K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$3K |
| D4342 |
|
17 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
20 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
253 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
232 |
227 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$568.32 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$210.32 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$166.35 |