| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
138 |
54 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
242 |
$5K |
| D1120 |
Prophylaxis - child |
130 |
124 |
$5K |
| D1351 |
Sealant - per tooth |
111 |
31 |
$4K |
| D0274 |
Bitewings - four radiographic images |
238 |
223 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
80 |
54 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
118 |
$3K |
| D9110 |
|
51 |
46 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
297 |
236 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
270 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
55 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$244.40 |