| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
307 |
295 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
85 |
51 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
222 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$726.48 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$436.80 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$312.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$198.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$94.64 |