| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,745 |
3,745 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,532 |
4,532 |
$91K |
| D0274 |
Bitewings - four radiographic images |
4,236 |
4,236 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
5,862 |
5,840 |
$49K |
| D9310 |
|
1,005 |
1,001 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,680 |
4,576 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,159 |
1,159 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
1,035 |
1,032 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
406 |
375 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
509 |
447 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
930 |
916 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
126 |
84 |
$6K |
| D1120 |
Prophylaxis - child |
199 |
198 |
$5K |
| D3310 |
|
12 |
12 |
$2K |
| D3320 |
|
38 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$948.00 |
| D0270 |
|
83 |
83 |
$637.52 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$251.75 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$178.21 |
| D3999 |
|
13 |
12 |
$0.00 |
| G9275 |
Documentation that patient is a current non-tobacco user |
18 |
17 |
$0.00 |
| 99499 |
|
14 |
12 |
$0.00 |
| S9470 |
Nutritional counseling, dietitian visit |
14 |
12 |
$0.00 |