| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
840 |
449 |
$54K |
| D4341 |
|
355 |
167 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
839 |
294 |
$46K |
| D1120 |
Prophylaxis - child |
609 |
586 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
347 |
195 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
819 |
799 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
934 |
906 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
510 |
497 |
$13K |
| D1351 |
Sealant - per tooth |
193 |
82 |
$10K |
| D0274 |
Bitewings - four radiographic images |
586 |
572 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
453 |
441 |
$8K |
| D0330 |
Panoramic radiographic image |
297 |
291 |
$6K |
| D0272 |
Bitewings - two radiographic images |
571 |
554 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
219 |
214 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
460 |
441 |
$2K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
149 |
$722.00 |