| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
1,049 |
977 |
$259K |
| D9410 |
|
364 |
310 |
$6K |
| D1120 |
Prophylaxis - child |
554 |
486 |
$5K |
| D1206 |
Topical application of fluoride varnish |
881 |
805 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
325 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
322 |
$951.07 |
| D1110 |
Prophylaxis - adult |
155 |
154 |
$620.42 |
| D0190 |
|
48 |
45 |
$501.72 |
| D0272 |
Bitewings - two radiographic images |
106 |
104 |
$486.72 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
42 |
$484.10 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$424.52 |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$287.22 |
| D0601 |
|
314 |
307 |
$175.00 |
| D0602 |
|
104 |
100 |
$160.00 |
| D0140 |
Limited oral evaluation - problem focused |
221 |
215 |
$122.52 |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
201 |
$99.83 |
| D0603 |
|
28 |
27 |
$45.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.28 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
16 |
$0.19 |
| D1999 |
|
52 |
52 |
$0.00 |
| D1330 |
|
501 |
496 |
$0.00 |