| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
945 |
421 |
$109K |
| D1110 |
Prophylaxis - adult |
1,302 |
1,291 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,669 |
1,661 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
1,319 |
1,316 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
1,521 |
1,513 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,367 |
1,282 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,017 |
2,005 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,130 |
1,128 |
$22K |
| D1120 |
Prophylaxis - child |
385 |
379 |
$13K |
| D4341 |
|
101 |
37 |
$6K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
59 |
28 |
$4K |
| D2160 |
|
21 |
12 |
$2K |
| D9430 |
|
40 |
40 |
$1K |
| D1999 |
|
19 |
19 |
$92.00 |