| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
232 |
74 |
$21K |
| D1120 |
Prophylaxis - child |
387 |
181 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
446 |
207 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
381 |
176 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
229 |
112 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
70 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
297 |
153 |
$3K |
| D1110 |
Prophylaxis - adult |
121 |
51 |
$3K |
| D4910 |
|
15 |
15 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
51 |
$740.80 |
| D0140 |
Limited oral evaluation - problem focused |
94 |
37 |
$729.00 |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
42 |
$347.20 |
| D0330 |
Panoramic radiographic image |
57 |
28 |
$293.80 |