| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
263 |
263 |
$1K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$799.00 |
| D0274 |
Bitewings - four radiographic images |
234 |
234 |
$725.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$722.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
48 |
$710.00 |
| D0180 |
|
125 |
125 |
$630.00 |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
296 |
$507.00 |
| D4341 |
|
65 |
51 |
$450.00 |
| D0603 |
|
262 |
262 |
$362.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
109 |
60 |
$320.00 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$315.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
271 |
253 |
$306.00 |
| D4342 |
|
46 |
29 |
$276.00 |
| D1206 |
Topical application of fluoride varnish |
68 |
67 |
$228.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
41 |
$224.00 |
| D1320 |
|
65 |
65 |
$20.09 |
| D1330 |
|
376 |
351 |
$0.01 |
| D1310 |
|
236 |
236 |
$0.00 |
| D9986 |
|
205 |
192 |
$0.00 |