| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
322 |
137 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
601 |
581 |
$21K |
| D0330 |
Panoramic radiographic image |
127 |
126 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
253 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
271 |
134 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
36 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
39 |
39 |
$812.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$451.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$450.17 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$378.00 |