| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
836 |
618 |
$72K |
| D1110 |
Prophylaxis - adult |
1,353 |
1,350 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,756 |
1,747 |
$43K |
| D2394 |
|
238 |
174 |
$28K |
| D0330 |
Panoramic radiographic image |
663 |
660 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
965 |
935 |
$11K |
| D0274 |
Bitewings - four radiographic images |
422 |
421 |
$10K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
202 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
104 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$908.90 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
25 |
$569.10 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$182.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$121.50 |