| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
74 |
29 |
$9K |
| D1110 |
Prophylaxis - adult |
68 |
65 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
104 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
59 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
47 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
87 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$952.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$948.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
57 |
$588.00 |