| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
120 |
42 |
$7K |
| D1120 |
Prophylaxis - child |
134 |
128 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$5K |
| D1206 |
Topical application of fluoride varnish |
108 |
102 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
87 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
89 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
54 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
138 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
121 |
$865.83 |