| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
125 |
124 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
193 |
83 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
39 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
153 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
21 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$986.79 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$444.45 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$362.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$205.20 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$170.22 |