| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
322 |
322 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
276 |
260 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
356 |
$769.92 |
| D0274 |
Bitewings - four radiographic images |
286 |
286 |
$578.17 |
| D1206 |
Topical application of fluoride varnish |
422 |
422 |
$511.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
803 |
286 |
$421.53 |
| D4355 |
|
140 |
140 |
$281.22 |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
326 |
$213.08 |
| D1330 |
|
377 |
376 |
$162.06 |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$0.00 |
| D1120 |
Prophylaxis - child |
120 |
120 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
30 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
38 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
57 |
57 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
75 |
$0.00 |
| D1351 |
Sealant - per tooth |
141 |
26 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
13 |
$0.00 |