| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
285 |
125 |
$40K |
| D1110 |
Prophylaxis - adult |
549 |
513 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
414 |
389 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
724 |
682 |
$9K |
| D0274 |
Bitewings - four radiographic images |
441 |
411 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
609 |
577 |
$7K |
| D1120 |
Prophylaxis - child |
335 |
322 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
286 |
265 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
478 |
$3K |
| D2160 |
|
69 |
40 |
$3K |
| D4212 |
|
272 |
108 |
$2K |
| D0330 |
Panoramic radiographic image |
43 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
86 |
$586.00 |
| D2161 |
|
50 |
26 |
$418.57 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
24 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$0.00 |