| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
685 |
270 |
$57K |
| D1120 |
Prophylaxis - child |
763 |
689 |
$32K |
| D1206 |
Topical application of fluoride varnish |
969 |
903 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
159 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,042 |
924 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
603 |
591 |
$22K |
| D1110 |
Prophylaxis - adult |
423 |
391 |
$20K |
| D0274 |
Bitewings - four radiographic images |
751 |
689 |
$20K |
| D0330 |
Panoramic radiographic image |
432 |
411 |
$18K |
| D1351 |
Sealant - per tooth |
298 |
100 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
199 |
57 |
$11K |
| D5110 |
|
26 |
26 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
755 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
982 |
869 |
$8K |
| D0272 |
Bitewings - two radiographic images |
151 |
151 |
$5K |
| D5120 |
|
12 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
153 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$1K |