| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
459 |
143 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
1,079 |
1,065 |
$25K |
| D5110 |
|
36 |
36 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
351 |
349 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$9K |
| D4341 |
|
277 |
91 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
367 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
958 |
926 |
$8K |
| D1999 |
|
512 |
406 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,612 |
318 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
155 |
154 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
14 |
$792.74 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$521.31 |