| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
862 |
381 |
$111K |
| D0140 |
Limited oral evaluation - problem focused |
847 |
838 |
$51K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
163 |
128 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
187 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
515 |
506 |
$10K |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$924.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
16 |
$255.58 |