| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
1,007 |
958 |
$70K |
| D1110 |
Prophylaxis - adult |
798 |
798 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
748 |
748 |
$14K |
| D1120 |
Prophylaxis - child |
550 |
550 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
100 |
$7K |
| D0274 |
Bitewings - four radiographic images |
342 |
342 |
$4K |
| D0330 |
Panoramic radiographic image |
258 |
258 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
234 |
$2K |
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
76 |
$650.00 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$594.00 |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
174 |
$391.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
28 |
$275.00 |