| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
626 |
228 |
$95K |
| D0330 |
Panoramic radiographic image |
701 |
624 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
701 |
622 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
240 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
34 |
$8K |
| D0274 |
Bitewings - four radiographic images |
93 |
81 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$868.70 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
17 |
$493.77 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$339.60 |