| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,555 |
990 |
$95K |
| D2394 |
|
1,311 |
898 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,757 |
1,728 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
1,964 |
1,920 |
$63K |
| D1120 |
Prophylaxis - child |
1,490 |
1,459 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,870 |
4,471 |
$40K |
| D1110 |
Prophylaxis - adult |
743 |
733 |
$40K |
| D9110 |
|
710 |
673 |
$29K |
| D0274 |
Bitewings - four radiographic images |
2,642 |
2,584 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,533 |
1,505 |
$27K |
| D9999 |
Unspecified adjunctive procedure, by report |
198 |
182 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
4,535 |
4,179 |
$25K |
| D0330 |
Panoramic radiographic image |
944 |
919 |
$13K |
| D2335 |
|
99 |
51 |
$9K |
| D0350 |
|
1,392 |
483 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
109 |
52 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
692 |
686 |
$8K |
| D1351 |
Sealant - per tooth |
252 |
74 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
12 |
12 |
$5K |
| D1999 |
|
717 |
579 |
$2K |
| D9430 |
|
136 |
125 |
$744.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
30 |
28 |
$0.00 |