| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
5,671 |
4,296 |
$752K |
| D1110 |
Prophylaxis - adult |
1,658 |
1,658 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
626 |
503 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
2,098 |
2,098 |
$1K |
| D0330 |
Panoramic radiographic image |
770 |
770 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
492 |
492 |
$566.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
41 |
$506.00 |
| D0274 |
Bitewings - four radiographic images |
936 |
936 |
$505.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
488 |
376 |
$270.00 |
| D1120 |
Prophylaxis - child |
505 |
505 |
$258.00 |
| D0140 |
Limited oral evaluation - problem focused |
479 |
477 |
$224.00 |
| D4910 |
|
119 |
119 |
$206.00 |
| D0220 |
Intraoral - periapical first radiographic image |
548 |
540 |
$177.00 |
| D0272 |
Bitewings - two radiographic images |
280 |
280 |
$96.00 |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$90.00 |
| D2330 |
|
34 |
26 |
$58.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
359 |
359 |
$14.00 |
| D0603 |
|
673 |
673 |
$0.00 |
| D0601 |
|
264 |
264 |
$0.00 |
| D0602 |
|
584 |
584 |
$0.00 |