| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
691 |
625 |
$158K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
281 |
122 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
255 |
111 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
137 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
999 |
399 |
$9K |
| D1120 |
Prophylaxis - child |
449 |
446 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
387 |
387 |
$8K |
| D1110 |
Prophylaxis - adult |
284 |
281 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
299 |
$7K |
| D1351 |
Sealant - per tooth |
232 |
56 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
566 |
561 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
452 |
$4K |
| D0274 |
Bitewings - four radiographic images |
184 |
182 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$1K |
| D0272 |
Bitewings - two radiographic images |
43 |
41 |
$322.40 |
| D0603 |
|
158 |
154 |
$0.00 |
| D0602 |
|
260 |
259 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
349 |
343 |
$0.00 |
| D0330 |
Panoramic radiographic image |
30 |
29 |
$0.00 |