| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
853 |
636 |
$76K |
| D1120 |
Prophylaxis - child |
1,647 |
1,550 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
969 |
621 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,873 |
1,779 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,638 |
1,539 |
$43K |
| D1351 |
Sealant - per tooth |
739 |
283 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
239 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
1,245 |
1,136 |
$22K |
| D0274 |
Bitewings - four radiographic images |
863 |
809 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,355 |
2,188 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
610 |
570 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
166 |
70 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
126 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
823 |
710 |
$4K |
| D0272 |
Bitewings - two radiographic images |
247 |
230 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$580.56 |