| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,087 |
670 |
$96K |
| D4341 |
|
400 |
216 |
$61K |
| D1120 |
Prophylaxis - child |
1,313 |
1,270 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,588 |
1,528 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,550 |
1,458 |
$37K |
| D0330 |
Panoramic radiographic image |
1,320 |
1,251 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,063 |
1,023 |
$28K |
| D1351 |
Sealant - per tooth |
461 |
171 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
298 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
576 |
407 |
$24K |
| D1110 |
Prophylaxis - adult |
373 |
364 |
$17K |
| D0274 |
Bitewings - four radiographic images |
838 |
792 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
331 |
290 |
$6K |
| D0272 |
Bitewings - two radiographic images |
744 |
722 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,212 |
1,066 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
76 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
258 |
$1K |