| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
556 |
504 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
765 |
694 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
594 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
13 |
$828.94 |
| D1206 |
Topical application of fluoride varnish |
170 |
167 |
$760.26 |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
134 |
$726.32 |
| D2950 |
|
17 |
15 |
$639.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
97 |
79 |
$221.18 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$194.40 |
| D1999 |
|
155 |
142 |
$9.75 |
| D4910 |
|
13 |
13 |
$0.00 |