| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
170 |
166 |
$13K |
| D0999 |
Unspecified diagnostic procedure, by report |
46 |
45 |
$3K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$498.75 |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$427.50 |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$256.50 |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
89 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
30 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
77 |
77 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
22 |
$0.00 |