| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,316 |
2,026 |
$333K |
| D1110 |
Prophylaxis - adult |
540 |
540 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
786 |
786 |
$3K |
| D0274 |
Bitewings - four radiographic images |
618 |
616 |
$1K |
| D1120 |
Prophylaxis - child |
504 |
501 |
$927.61 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$379.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
83 |
$290.16 |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
48 |
$220.49 |
| D0220 |
Intraoral - periapical first radiographic image |
747 |
736 |
$204.46 |
| D1206 |
Topical application of fluoride varnish |
200 |
199 |
$166.63 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$82.50 |
| D0120 |
Periodic oral evaluation - established patient |
410 |
410 |
$56.89 |
| D0330 |
Panoramic radiographic image |
106 |
106 |
$30.40 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
68 |
49 |
$20.84 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$17.04 |
| D0140 |
Limited oral evaluation - problem focused |
151 |
151 |
$9.99 |
| D1330 |
|
698 |
691 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$0.00 |
| D4355 |
|
125 |
125 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
27 |
$0.00 |
| D1310 |
|
72 |
72 |
$0.00 |
| D1351 |
Sealant - per tooth |
73 |
14 |
$0.00 |
| D9430 |
|
58 |
56 |
$0.00 |