| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8030 |
|
328 |
323 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
257 |
40 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
376 |
323 |
$11K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
234 |
227 |
$10K |
| D0330 |
Panoramic radiographic image |
65 |
59 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
16 |
16 |
$4K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
78 |
72 |
$3K |
| 70355 |
|
73 |
69 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
33 |
$858.85 |
| D1120 |
Prophylaxis - child |
31 |
30 |
$500.00 |
| D1206 |
Topical application of fluoride varnish |
33 |
32 |
$450.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$439.56 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$204.64 |