| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
311 |
41 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
58 |
32 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
137 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
128 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
153 |
145 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
95 |
$3K |
| D1120 |
Prophylaxis - child |
99 |
98 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
48 |
$2K |
| D1110 |
Prophylaxis - adult |
73 |
67 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
122 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
118 |
$2K |