| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7240 |
Removal of impacted tooth - completely bony |
42 |
13 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
26 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$1K |
| D1120 |
Prophylaxis - child |
20 |
20 |
$634.12 |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$618.60 |
| D1206 |
Topical application of fluoride varnish |
20 |
20 |
$528.20 |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$520.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$466.62 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$432.12 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
22 |
$365.64 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
34 |
$339.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
21 |
$276.83 |