| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,881 |
1,876 |
$76K |
| D1110 |
Prophylaxis - adult |
869 |
868 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,021 |
1,012 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,285 |
2,275 |
$47K |
| D9999 |
Unspecified adjunctive procedure, by report |
351 |
329 |
$41K |
| D1120 |
Prophylaxis - child |
1,306 |
1,302 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
105 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
2,255 |
2,236 |
$9K |
| D0274 |
Bitewings - four radiographic images |
1,065 |
1,063 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
532 |
531 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
12 |
$5K |
| D4341 |
|
108 |
29 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,864 |
1,834 |
$4K |
| D4910 |
|
70 |
70 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
13 |
$2K |
| D9430 |
|
60 |
58 |
$994.00 |
| D9995 |
|
58 |
56 |
$734.40 |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$720.00 |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$203.00 |
| D0140 |
Limited oral evaluation - problem focused |
221 |
213 |
$184.80 |
| D9993 |
|
37 |
37 |
$0.00 |
| D1999 |
|
51 |
45 |
$0.00 |
| D1330 |
|
58 |
56 |
$0.00 |
| D1310 |
|
37 |
37 |
$0.00 |