| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
128 |
54 |
$7K |
| D0330 |
Panoramic radiographic image |
81 |
68 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$1K |
| D1110 |
Prophylaxis - adult |
48 |
42 |
$1K |
| D0274 |
Bitewings - four radiographic images |
75 |
62 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
32 |
$633.40 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$182.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$86.32 |