| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
250 |
91 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
241 |
$8K |
| D4341 |
|
169 |
45 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
35 |
$8K |
| D3310 |
|
25 |
14 |
$8K |
| D1110 |
Prophylaxis - adult |
188 |
188 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
183 |
183 |
$7K |
| D9430 |
|
197 |
184 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,321 |
258 |
$4K |
| D1120 |
Prophylaxis - child |
116 |
115 |
$3K |
| D5750 |
|
15 |
15 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
30 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
121 |
120 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
236 |
221 |
$2K |
| D5751 |
|
12 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
303 |
302 |
$2K |
| D0274 |
Bitewings - four radiographic images |
96 |
95 |
$2K |
| D1351 |
Sealant - per tooth |
63 |
14 |
$1K |
| D5850 |
|
12 |
12 |
$840.00 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$170.00 |
| D0350 |
|
21 |
15 |
$150.00 |