| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
332 |
328 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
40 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$331.10 |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$260.94 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$110.40 |
| D0601 |
|
38 |
38 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$0.00 |