| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
198 |
198 |
$5K |
| D1120 |
Prophylaxis - child |
281 |
281 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
96 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
101 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
206 |
206 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
110 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$652.35 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
27 |
$638.01 |
| D1206 |
Topical application of fluoride varnish |
217 |
217 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
215 |
215 |
$0.00 |