| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
680 |
677 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
92 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
135 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
30 |
$3K |
| D1120 |
Prophylaxis - child |
383 |
383 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
42 |
$1K |
| D1206 |
Topical application of fluoride varnish |
362 |
362 |
$391.41 |
| D0601 |
|
133 |
133 |
$130.47 |
| D0274 |
Bitewings - four radiographic images |
181 |
181 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
91 |
$0.00 |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$0.00 |
| D0602 |
|
202 |
202 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$0.00 |