| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
452 |
179 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
1,192 |
1,029 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
414 |
183 |
$30K |
| D0330 |
Panoramic radiographic image |
511 |
450 |
$26K |
| D1110 |
Prophylaxis - adult |
348 |
308 |
$16K |
| D0274 |
Bitewings - four radiographic images |
259 |
232 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
209 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
74 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$352.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
25 |
$330.00 |