| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
925 |
913 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
449 |
441 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
460 |
344 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
61 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
510 |
496 |
$4K |
| D0274 |
Bitewings - four radiographic images |
564 |
557 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,145 |
1,104 |
$4K |
| D1110 |
Prophylaxis - adult |
242 |
241 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
275 |
191 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,006 |
758 |
$2K |
| D1206 |
Topical application of fluoride varnish |
402 |
400 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
487 |
483 |
$2K |
| D1120 |
Prophylaxis - child |
169 |
169 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
60 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
98 |
$456.00 |
| D4910 |
|
15 |
15 |
$350.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
13 |
$110.00 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$60.00 |
| D1330 |
|
206 |
205 |
$0.00 |
| D1310 |
|
89 |
88 |
$0.00 |
| D9986 |
|
342 |
317 |
$0.00 |