| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
57 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
101 |
53 |
$10K |
| D5110 |
|
12 |
12 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
254 |
247 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
111 |
111 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
183 |
$4K |
| D1110 |
Prophylaxis - adult |
113 |
113 |
$4K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
39 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
125 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
25 |
$596.82 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$585.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
35 |
$432.14 |