| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
880 |
880 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
687 |
498 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,029 |
1,029 |
$7K |
| D1110 |
Prophylaxis - adult |
692 |
692 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,728 |
1,700 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
640 |
632 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
355 |
261 |
$4K |
| D1120 |
Prophylaxis - child |
425 |
425 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,738 |
1,298 |
$4K |
| D1206 |
Topical application of fluoride varnish |
1,023 |
1,022 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
756 |
756 |
$2K |
| D4910 |
|
144 |
143 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$986.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
46 |
$924.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
38 |
$800.00 |
| D2331 |
|
19 |
14 |
$648.00 |
| D4355 |
|
27 |
27 |
$567.00 |
| D4341 |
|
21 |
14 |
$540.00 |
| D2330 |
|
40 |
27 |
$464.00 |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$260.00 |
| D0603 |
|
120 |
120 |
$244.75 |
| D0601 |
|
43 |
43 |
$121.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$52.00 |
| D1330 |
|
2,201 |
2,115 |
$0.22 |
| D1310 |
|
223 |
223 |
$0.01 |
| D9986 |
|
864 |
817 |
$0.00 |