| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
849 |
846 |
$443.30 |
| D0330 |
Panoramic radiographic image |
626 |
623 |
$318.00 |
| D1110 |
Prophylaxis - adult |
262 |
262 |
$225.20 |
| D7140 |
Extraction, erupted tooth or exposed root |
353 |
159 |
$200.58 |
| D4355 |
|
143 |
142 |
$156.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
563 |
562 |
$147.00 |
| D0120 |
Periodic oral evaluation - established patient |
215 |
214 |
$146.80 |
| D0220 |
Intraoral - periapical first radiographic image |
653 |
638 |
$106.40 |
| D4341 |
|
56 |
55 |
$95.00 |
| D1120 |
Prophylaxis - child |
102 |
102 |
$90.00 |
| D0140 |
Limited oral evaluation - problem focused |
378 |
361 |
$77.60 |
| D1206 |
Topical application of fluoride varnish |
107 |
106 |
$74.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
282 |
271 |
$40.80 |
| D1351 |
Sealant - per tooth |
12 |
12 |
$0.00 |
| D0270 |
|
180 |
177 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
12 |
$0.00 |