| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,210 |
1,185 |
$56K |
| D0330 |
Panoramic radiographic image |
952 |
904 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
394 |
271 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,001 |
955 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
661 |
398 |
$14K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
223 |
205 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
425 |
236 |
$11K |
| D1206 |
Topical application of fluoride varnish |
1,706 |
1,669 |
$8K |
| D1351 |
Sealant - per tooth |
1,057 |
365 |
$5K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
58 |
50 |
$5K |
| D1330 |
|
2,804 |
2,709 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
218 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
952 |
866 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
250 |
249 |
$3K |
| D4341 |
|
188 |
79 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
70 |
$2K |
| D0191 |
|
1,190 |
1,174 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
42 |
42 |
$840.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
36 |
36 |
$720.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$719.23 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$702.71 |
| D0220 |
Intraoral - periapical first radiographic image |
1,327 |
1,235 |
$671.84 |
| D0274 |
Bitewings - four radiographic images |
748 |
719 |
$476.87 |
| D0270 |
|
30 |
30 |
$12.98 |
| 1159F |
|
155 |
132 |
$0.00 |
| 1158F |
|
13 |
12 |
$0.00 |
| 1160F |
|
131 |
108 |
$0.00 |
| 4004F |
|
35 |
27 |
$0.00 |
| 1000F |
|
178 |
149 |
$0.00 |
| 3008F |
|
268 |
227 |
$0.00 |
| 1157F |
|
13 |
12 |
$0.00 |
| 1126F |
|
125 |
105 |
$0.00 |
| 0513F |
|
60 |
54 |
$0.00 |
| D1320 |
|
95 |
95 |
$0.00 |
| 1101F |
|
12 |
12 |
$0.00 |