| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,196 |
247 |
$153K |
| D0330 |
Panoramic radiographic image |
501 |
501 |
$25K |
| D1110 |
Prophylaxis - adult |
447 |
440 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
660 |
649 |
$20K |
| D0274 |
Bitewings - four radiographic images |
578 |
572 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,075 |
1,050 |
$16K |
| D1206 |
Topical application of fluoride varnish |
832 |
818 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,287 |
898 |
$10K |
| D5226 |
|
12 |
12 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
289 |
283 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
60 |
$2K |
| D1351 |
Sealant - per tooth |
61 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$396.37 |