| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,235 |
454 |
$142K |
| D1351 |
Sealant - per tooth |
3,605 |
396 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
1,448 |
1,427 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
777 |
443 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,708 |
1,668 |
$44K |
| D4355 |
|
325 |
320 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
281 |
172 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
288 |
179 |
$16K |
| D1110 |
Prophylaxis - adult |
372 |
360 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
419 |
416 |
$7K |
| D0330 |
Panoramic radiographic image |
133 |
131 |
$7K |
| D1120 |
Prophylaxis - child |
190 |
187 |
$5K |
| D2394 |
|
17 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
57 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
103 |
$1K |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$730.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
74 |
$562.41 |