| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,267 |
490 |
$148K |
| D9110 |
|
1,845 |
1,561 |
$115K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,788 |
1,784 |
$101K |
| D1110 |
Prophylaxis - adult |
1,248 |
1,244 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,164 |
2,159 |
$85K |
| D1120 |
Prophylaxis - child |
2,046 |
2,041 |
$61K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,484 |
2,470 |
$54K |
| D1351 |
Sealant - per tooth |
1,749 |
344 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
748 |
748 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,569 |
1,565 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,826 |
1,825 |
$17K |
| D2140 |
|
307 |
166 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
951 |
950 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
179 |
108 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
91 |
$9K |
| D2161 |
|
63 |
38 |
$5K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$720.00 |