| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
642 |
606 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,166 |
1,074 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
39 |
$323.60 |
| D2950 |
|
14 |
12 |
$162.68 |
| D1206 |
Topical application of fluoride varnish |
47 |
46 |
$80.09 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$75.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
29 |
$52.00 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$44.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
140 |
$7.40 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |