| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
306 |
194 |
$25K |
| D1351 |
Sealant - per tooth |
291 |
162 |
$22K |
| D1120 |
Prophylaxis - child |
400 |
400 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
550 |
550 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
131 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
402 |
402 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
143 |
$10K |
| D4341 |
|
57 |
29 |
$8K |
| D1110 |
Prophylaxis - adult |
169 |
169 |
$8K |
| D0274 |
Bitewings - four radiographic images |
380 |
380 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
917 |
891 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
289 |
$6K |
| D9110 |
|
97 |
90 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
698 |
689 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
54 |
$572.74 |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$554.50 |