| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
423 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
94 |
$6K |
| D4355 |
|
66 |
64 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
618 |
608 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
14 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
524 |
518 |
$851.50 |
| D1330 |
|
238 |
233 |
$384.75 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$266.43 |
| D0330 |
Panoramic radiographic image |
329 |
325 |
$207.33 |
| D0274 |
Bitewings - four radiographic images |
269 |
264 |
$162.30 |
| D3120 |
|
22 |
15 |
$108.21 |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
229 |
$70.68 |
| D4921 |
|
115 |
92 |
$0.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$0.00 |
| D9911 |
|
75 |
36 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
215 |
214 |
$0.00 |