| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
91 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
14 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$512.40 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$511.95 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$405.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$280.00 |