| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
4,922 |
4,479 |
$703K |
| D1110 |
Prophylaxis - adult |
1,139 |
1,139 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
536 |
313 |
$951.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,737 |
1,735 |
$638.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,097 |
1,074 |
$340.00 |
| D0274 |
Bitewings - four radiographic images |
722 |
722 |
$318.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
561 |
561 |
$203.00 |
| D0140 |
Limited oral evaluation - problem focused |
277 |
276 |
$168.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
388 |
$165.90 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
422 |
336 |
$160.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
78 |
$71.00 |
| D0330 |
Panoramic radiographic image |
335 |
335 |
$40.00 |
| D0272 |
Bitewings - two radiographic images |
383 |
382 |
$17.00 |
| D1120 |
Prophylaxis - child |
1,107 |
1,107 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,334 |
1,334 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
538 |
465 |
$0.00 |
| D1351 |
Sealant - per tooth |
72 |
20 |
$0.00 |