| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
130 |
129 |
$13K |
| D1110 |
Prophylaxis - adult |
172 |
147 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
41 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
28 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$888.16 |