| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
583 |
583 |
$658.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
259 |
$608.00 |
| D0274 |
Bitewings - four radiographic images |
538 |
538 |
$522.00 |
| D1120 |
Prophylaxis - child |
454 |
453 |
$520.00 |
| D0120 |
Periodic oral evaluation - established patient |
783 |
783 |
$504.00 |
| D1206 |
Topical application of fluoride varnish |
814 |
814 |
$399.00 |
| D0220 |
Intraoral - periapical first radiographic image |
815 |
807 |
$351.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
36 |
$320.00 |
| D0140 |
Limited oral evaluation - problem focused |
242 |
239 |
$315.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
100 |
$213.00 |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$174.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
692 |
648 |
$171.00 |
| D1351 |
Sealant - per tooth |
212 |
101 |
$140.00 |
| D0270 |
|
40 |
39 |
$33.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
38 |
$0.00 |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$0.00 |
| D0190 |
|
50 |
50 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$0.00 |
| D1330 |
|
276 |
276 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
27 |
27 |
$0.00 |
| D1310 |
|
13 |
13 |
$0.00 |
| D4355 |
|
29 |
29 |
$0.00 |