| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
670 |
126 |
$115K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,123 |
275 |
$115K |
| D1110 |
Prophylaxis - adult |
1,791 |
1,702 |
$109K |
| D0140 |
Limited oral evaluation - problem focused |
1,542 |
1,418 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,162 |
1,038 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
2,672 |
2,468 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,082 |
972 |
$47K |
| D0330 |
Panoramic radiographic image |
560 |
500 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,587 |
993 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
406 |
351 |
$14K |
| D4910 |
|
85 |
85 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
39 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
20 |
$4K |
| D0270 |
|
45 |
44 |
$966.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
16 |
$483.00 |