| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
506 |
305 |
$51K |
| D1120 |
Prophylaxis - child |
918 |
918 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,160 |
1,160 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
370 |
123 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,070 |
1,040 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,796 |
975 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
866 |
866 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,444 |
1,378 |
$14K |
| D1110 |
Prophylaxis - adult |
244 |
243 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
55 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
396 |
384 |
$7K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$4K |
| D0272 |
Bitewings - two radiographic images |
109 |
109 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
40 |
13 |
$1K |