| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
86 |
38 |
$10K |
| D1351 |
Sealant - per tooth |
167 |
23 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
55 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
40 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
43 |
$840.00 |
| D1120 |
Prophylaxis - child |
33 |
32 |
$720.00 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
62 |
$708.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
33 |
$527.00 |