| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,315 |
2,300 |
$135K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,694 |
1,682 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,221 |
2,208 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
960 |
646 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
1,546 |
1,533 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,952 |
2,932 |
$37K |
| D1120 |
Prophylaxis - child |
1,254 |
1,243 |
$33K |
| D9999 |
Unspecified adjunctive procedure, by report |
277 |
263 |
$32K |
| D9430 |
|
1,406 |
1,379 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
56 |
45 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
231 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,335 |
1,329 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,383 |
2,618 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,548 |
2,347 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
24 |
$2K |
| D0270 |
|
623 |
615 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
22 |
22 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
65 |
65 |
$916.49 |
| D1999 |
|
412 |
340 |
$390.00 |
| D1310 |
|
64 |
64 |
$368.36 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$60.00 |
| D0601 |
|
123 |
123 |
$49.00 |
| D9993 |
|
40 |
40 |
$0.00 |
| D1330 |
|
273 |
273 |
$0.00 |