| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
63 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
143 |
$507.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$456.00 |
| D0603 |
|
13 |
13 |
$121.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
12 |
$9.00 |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$0.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$0.00 |
| D1330 |
|
25 |
25 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$0.00 |