| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,068 |
349 |
$66K |
| D1351 |
Sealant - per tooth |
747 |
197 |
$27K |
| D1120 |
Prophylaxis - child |
598 |
584 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
600 |
586 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
132 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
653 |
638 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
534 |
507 |
$13K |
| D0274 |
Bitewings - four radiographic images |
652 |
633 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
216 |
71 |
$10K |
| D0330 |
Panoramic radiographic image |
358 |
342 |
$8K |
| D5110 |
|
20 |
19 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,168 |
1,131 |
$6K |
| D5120 |
|
18 |
17 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,004 |
937 |
$4K |
| D1110 |
Prophylaxis - adult |
153 |
139 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
31 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
196 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
52 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
431 |
416 |
$3K |
| D0272 |
Bitewings - two radiographic images |
256 |
252 |
$2K |