| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
897 |
297 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,323 |
1,018 |
$29K |
| D0330 |
Panoramic radiographic image |
725 |
513 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
429 |
270 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
756 |
640 |
$7K |
| D1120 |
Prophylaxis - child |
197 |
126 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
165 |
29 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
117 |
$2K |
| D1206 |
Topical application of fluoride varnish |
166 |
110 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
330 |
237 |
$2K |
| D7230 |
|
28 |
13 |
$1K |
| D4355 |
|
50 |
29 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
17 |
$738.00 |
| D9994 |
|
70 |
58 |
$574.00 |
| D9993 |
|
71 |
58 |
$574.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$494.97 |
| D9310 |
|
20 |
17 |
$430.50 |
| D5899 |
|
80 |
45 |
$369.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$284.44 |
| D9420 |
|
66 |
37 |
$245.94 |