| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
105 |
$5K |
| D0240 |
|
262 |
111 |
$4K |
| D1120 |
Prophylaxis - child |
130 |
111 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
89 |
72 |
$1K |
| D0272 |
Bitewings - two radiographic images |
37 |
35 |
$580.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$422.73 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
12 |
$411.72 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$224.77 |