| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,504 |
1,048 |
$265K |
| D1351 |
Sealant - per tooth |
11,498 |
1,182 |
$257K |
| D0210 |
Intraoral - complete series of radiographic images |
3,853 |
3,815 |
$216K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,238 |
1,046 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,290 |
4,251 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,665 |
740 |
$87K |
| D1110 |
Prophylaxis - adult |
1,960 |
1,946 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,970 |
1,949 |
$33K |
| D1120 |
Prophylaxis - child |
1,158 |
1,149 |
$33K |
| D0330 |
Panoramic radiographic image |
599 |
587 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
996 |
989 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
124 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
195 |
71 |
$10K |
| D0274 |
Bitewings - four radiographic images |
379 |
377 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
292 |
285 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
569 |
$6K |
| D4341 |
|
53 |
16 |
$5K |
| D4355 |
|
52 |
52 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
429 |
405 |
$3K |
| D4346 |
|
29 |
29 |
$3K |
| D2335 |
|
28 |
18 |
$3K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$216.60 |