| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,008 |
1,974 |
$351K |
| D1110 |
Prophylaxis - adult |
1,650 |
1,650 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
3,005 |
3,005 |
$52K |
| D1120 |
Prophylaxis - child |
1,268 |
1,268 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,194 |
1,194 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,564 |
1,564 |
$12K |
| D0330 |
Panoramic radiographic image |
378 |
378 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,009 |
1,002 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
237 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
32 |
$2K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$382.50 |