| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
582 |
155 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
510 |
308 |
$15K |
| D7311 |
|
222 |
98 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,014 |
271 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
643 |
382 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
52 |
$2K |
| D0274 |
Bitewings - four radiographic images |
127 |
82 |
$2K |
| D1120 |
Prophylaxis - child |
100 |
54 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
33 |
$515.25 |