| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
417 |
416 |
$5K |
| D1206 |
Topical application of fluoride varnish |
767 |
761 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
751 |
$4K |
| D1110 |
Prophylaxis - adult |
493 |
490 |
$3K |
| D0274 |
Bitewings - four radiographic images |
403 |
401 |
$2K |
| D1120 |
Prophylaxis - child |
479 |
479 |
$2K |
| D2140 |
|
441 |
190 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
632 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
323 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
561 |
456 |
$752.31 |
| D0140 |
Limited oral evaluation - problem focused |
397 |
388 |
$744.72 |
| D0272 |
Bitewings - two radiographic images |
279 |
279 |
$698.88 |
| D1330 |
|
233 |
233 |
$530.55 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
93 |
57 |
$481.86 |
| D7140 |
Extraction, erupted tooth or exposed root |
150 |
70 |
$459.68 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
12 |
$0.00 |