| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
236 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
29 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
231 |
231 |
$645.75 |
| D1206 |
Topical application of fluoride varnish |
127 |
127 |
$464.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
51 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
170 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |