| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
641 |
599 |
$151K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
36 |
$806.41 |
| D1120 |
Prophylaxis - child |
198 |
196 |
$770.45 |
| D0120 |
Periodic oral evaluation - established patient |
289 |
286 |
$759.79 |
| D1206 |
Topical application of fluoride varnish |
365 |
362 |
$695.51 |
| D1110 |
Prophylaxis - adult |
153 |
152 |
$670.38 |
| D1351 |
Sealant - per tooth |
266 |
41 |
$654.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
80 |
$314.45 |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$278.38 |
| D0602 |
|
89 |
88 |
$185.00 |
| D0272 |
Bitewings - two radiographic images |
71 |
70 |
$179.13 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
19 |
$136.12 |
| D0601 |
|
233 |
227 |
$85.00 |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
88 |
$73.54 |
| D0140 |
Limited oral evaluation - problem focused |
85 |
83 |
$72.34 |
| D0603 |
|
30 |
30 |
$60.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
33 |
$0.53 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$0.10 |
| D1330 |
|
381 |
377 |
$0.00 |