| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,102 |
263 |
$10K |
| D7250 |
|
325 |
64 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
313 |
$2K |
| D0330 |
Panoramic radiographic image |
473 |
254 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
39 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
395 |
208 |
$642.55 |
| D1110 |
Prophylaxis - adult |
444 |
242 |
$597.66 |
| D0120 |
Periodic oral evaluation - established patient |
328 |
168 |
$248.38 |
| D0274 |
Bitewings - four radiographic images |
172 |
101 |
$246.19 |
| D4355 |
|
74 |
26 |
$196.28 |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
86 |
$92.75 |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
12 |
$0.00 |