| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
384 |
307 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
837 |
779 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
233 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
101 |
$4K |
| D9110 |
|
48 |
43 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
24 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
25 |
$907.53 |
| D0274 |
Bitewings - four radiographic images |
33 |
19 |
$523.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$60.80 |