| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
701 |
230 |
$33K |
| D1110 |
Prophylaxis - adult |
935 |
932 |
$30K |
| D0274 |
Bitewings - four radiographic images |
942 |
939 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
893 |
887 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
211 |
107 |
$13K |
| D1351 |
Sealant - per tooth |
548 |
79 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,251 |
1,204 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
473 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
945 |
917 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
463 |
458 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
256 |
236 |
$4K |
| D1120 |
Prophylaxis - child |
161 |
157 |
$4K |
| D0330 |
Panoramic radiographic image |
110 |
110 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
13 |
$2K |
| D9110 |
|
36 |
34 |
$1K |