| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
90 |
44 |
$7K |
| D0330 |
Panoramic radiographic image |
120 |
119 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
189 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
193 |
$1K |
| D0274 |
Bitewings - four radiographic images |
68 |
66 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
114 |
98 |
$497.44 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$346.23 |