| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
247 |
78 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
453 |
452 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
635 |
634 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
28 |
14 |
$19K |
| D1351 |
Sealant - per tooth |
397 |
54 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
171 |
$3K |
| D1206 |
Topical application of fluoride varnish |
147 |
147 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$1K |
| D4346 |
|
12 |
12 |
$792.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
64 |
$698.50 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$465.90 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$138.00 |
| D0270 |
|
13 |
13 |
$48.00 |