| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
2,273 |
2,191 |
$169K |
| D9999 |
Unspecified adjunctive procedure, by report |
213 |
202 |
$16K |
| D1110 |
Prophylaxis - adult |
667 |
667 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
670 |
669 |
$830.53 |
| D0274 |
Bitewings - four radiographic images |
592 |
591 |
$719.23 |
| D0220 |
Intraoral - periapical first radiographic image |
926 |
923 |
$492.75 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
67 |
$250.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
587 |
585 |
$218.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
27 |
$41.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$13.83 |