| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
152 |
68 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$906.66 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$794.82 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$558.72 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$414.96 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$368.81 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$321.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
34 |
$305.20 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$283.79 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$235.80 |