| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
517 |
240 |
$52K |
| D0330 |
Panoramic radiographic image |
798 |
633 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
665 |
495 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
487 |
$20K |
| D1120 |
Prophylaxis - child |
669 |
523 |
$15K |
| D7311 |
|
159 |
132 |
$15K |
| D1351 |
Sealant - per tooth |
705 |
64 |
$15K |
| D1206 |
Topical application of fluoride varnish |
634 |
492 |
$12K |
| D0272 |
Bitewings - two radiographic images |
506 |
383 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$882.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$360.92 |