| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,052 |
448 |
$85K |
| D1120 |
Prophylaxis - child |
1,232 |
1,232 |
$53K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
415 |
260 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,171 |
1,171 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
620 |
620 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
603 |
603 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,094 |
1,091 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,445 |
1,424 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
486 |
479 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$5K |
| D0330 |
Panoramic radiographic image |
137 |
137 |
$4K |
| D0274 |
Bitewings - four radiographic images |
176 |
176 |
$3K |
| D0272 |
Bitewings - two radiographic images |
307 |
307 |
$3K |
| D0270 |
|
159 |
159 |
$884.80 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$856.80 |