| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,010 |
1,892 |
$514K |
| D0120 |
Periodic oral evaluation - established patient |
1,225 |
1,218 |
$7K |
| D1120 |
Prophylaxis - child |
737 |
733 |
$6K |
| D1206 |
Topical application of fluoride varnish |
1,507 |
1,498 |
$6K |
| D1351 |
Sealant - per tooth |
597 |
82 |
$5K |
| D1110 |
Prophylaxis - adult |
622 |
617 |
$5K |
| D0274 |
Bitewings - four radiographic images |
415 |
414 |
$3K |
| D0330 |
Panoramic radiographic image |
169 |
166 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
48 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
74 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
184 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
18 |
$1K |
| D0272 |
Bitewings - two radiographic images |
191 |
190 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
419 |
$926.01 |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
131 |
$563.53 |
| D0603 |
|
654 |
647 |
$450.00 |
| D0140 |
Limited oral evaluation - problem focused |
132 |
126 |
$311.28 |
| D0602 |
|
446 |
446 |
$275.00 |
| D0601 |
|
326 |
325 |
$220.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
28 |
$119.42 |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
174 |
$5.43 |
| D4910 |
|
97 |
97 |
$0.94 |
| D1330 |
|
1,568 |
1,561 |
$0.00 |
| D1310 |
|
1,567 |
1,560 |
$0.00 |