| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
46 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
22 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
289 |
175 |
$3K |
| D1110 |
Prophylaxis - adult |
162 |
62 |
$2K |
| D0330 |
Panoramic radiographic image |
123 |
56 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
144 |
$884.72 |
| D0120 |
Periodic oral evaluation - established patient |
146 |
53 |
$744.72 |
| D0274 |
Bitewings - four radiographic images |
168 |
64 |
$567.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
15 |
$407.80 |
| D1999 |
|
29 |
24 |
$390.00 |
| D1206 |
Topical application of fluoride varnish |
67 |
31 |
$380.08 |