| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,248 |
771 |
$110K |
| D1110 |
Prophylaxis - adult |
506 |
506 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
85 |
$863.09 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$437.45 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$187.18 |