| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
1,450 |
1,404 |
$106K |
| D1110 |
Prophylaxis - adult |
256 |
256 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$525.00 |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
503 |
$504.55 |
| D0274 |
Bitewings - four radiographic images |
302 |
302 |
$195.26 |
| D0120 |
Periodic oral evaluation - established patient |
323 |
323 |
$187.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$168.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
38 |
$102.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
324 |
324 |
$73.83 |
| D1330 |
|
12 |
12 |
$0.00 |