| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
442 |
110 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
146 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
287 |
$9K |
| D1110 |
Prophylaxis - adult |
86 |
86 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
61 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$526.64 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$313.32 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$285.83 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$135.30 |