| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
15 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
149 |
$6K |
| D2335 |
|
38 |
14 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
34 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
15 |
$854.79 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$819.44 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$800.69 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
56 |
$547.08 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
15 |
$309.31 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
13 |
$151.00 |