| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
426 |
172 |
$80K |
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
37 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
279 |
220 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
172 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
155 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
26 |
$4K |
| D0330 |
Panoramic radiographic image |
54 |
53 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
77 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
31 |
30 |
$823.20 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$806.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
33 |
$380.12 |