| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
216 |
75 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
449 |
220 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
250 |
148 |
$7K |
| D1120 |
Prophylaxis - child |
415 |
214 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
375 |
201 |
$3K |
| D1351 |
Sealant - per tooth |
121 |
17 |
$3K |
| D0330 |
Panoramic radiographic image |
146 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
77 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
28 |
$816.63 |