| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,569 |
2,402 |
$372K |
| D1120 |
Prophylaxis - child |
749 |
749 |
$40.85 |
| D0120 |
Periodic oral evaluation - established patient |
1,081 |
1,081 |
$27.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
693 |
693 |
$13.30 |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$0.00 |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
45 |
$0.00 |
| D9995 |
|
157 |
156 |
$0.00 |
| D1310 |
|
148 |
148 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
339 |
339 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
237 |
237 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
44 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
29 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$0.00 |
| D1330 |
|
149 |
149 |
$0.00 |
| D1351 |
Sealant - per tooth |
157 |
55 |
$0.00 |
| D9310 |
|
17 |
17 |
$0.00 |
| D0171 |
|
13 |
13 |
$0.00 |