| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
134 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$996.39 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$453.92 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$279.19 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$241.54 |