| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4212 |
|
1,161 |
414 |
$351K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,038 |
453 |
$126K |
| D2161 |
|
467 |
233 |
$42K |
| D2160 |
|
507 |
290 |
$37K |
| D1110 |
Prophylaxis - adult |
956 |
921 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
810 |
756 |
$22K |
| D0274 |
Bitewings - four radiographic images |
746 |
712 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,090 |
1,037 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
510 |
485 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
673 |
629 |
$9K |
| D0330 |
Panoramic radiographic image |
171 |
162 |
$8K |
| D1120 |
Prophylaxis - child |
365 |
334 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
901 |
830 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
115 |
71 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
615 |
389 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
80 |
$3K |
| D0272 |
Bitewings - two radiographic images |
67 |
62 |
$975.03 |