| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
1,325 |
1,236 |
$270K |
| D1110 |
Prophylaxis - adult |
1,492 |
1,308 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,251 |
1,965 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,224 |
1,942 |
$48K |
| D1120 |
Prophylaxis - child |
1,404 |
1,261 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
561 |
205 |
$39K |
| T1015 |
Clinic visit/encounter, all-inclusive |
666 |
618 |
$9K |
| D1354 |
|
125 |
15 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
412 |
377 |
$3K |
| D0272 |
Bitewings - two radiographic images |
133 |
117 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
251 |
$3K |
| D2330 |
|
40 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$598.40 |
| D1206 |
Topical application of fluoride varnish |
117 |
116 |
$519.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
13 |
$352.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
28 |
$66.00 |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$0.00 |