| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
28 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
103 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
43 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$947.88 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$761.70 |
| D1206 |
Topical application of fluoride varnish |
34 |
34 |
$601.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$597.78 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$414.44 |