| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,439 |
1,439 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
989 |
988 |
$8K |
| D1110 |
Prophylaxis - adult |
1,618 |
1,616 |
$8K |
| D1206 |
Topical application of fluoride varnish |
2,627 |
2,617 |
$6K |
| D4342 |
|
581 |
338 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
807 |
799 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
413 |
296 |
$4K |
| D4341 |
|
320 |
187 |
$3K |
| D1120 |
Prophylaxis - child |
506 |
505 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,133 |
1,112 |
$2K |
| D4910 |
|
214 |
214 |
$2K |
| D0274 |
Bitewings - four radiographic images |
452 |
452 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
97 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
73 |
$1K |
| D1351 |
Sealant - per tooth |
277 |
68 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
434 |
434 |
$980.00 |
| D0603 |
|
435 |
435 |
$770.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
912 |
511 |
$738.00 |
| D0270 |
|
415 |
408 |
$605.00 |
| D0602 |
|
223 |
223 |
$473.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
36 |
$400.00 |
| D1354 |
|
439 |
117 |
$350.00 |
| D1330 |
|
3,198 |
3,187 |
$160.00 |
| D1320 |
|
88 |
88 |
$140.00 |
| D0180 |
|
14 |
14 |
$126.00 |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$104.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$100.00 |
| D1310 |
|
3,108 |
3,100 |
$30.00 |
| D9995 |
|
246 |
246 |
$15.00 |
| D0191 |
|
12 |
12 |
$0.00 |