| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
802 |
657 |
$124K |
| D1110 |
Prophylaxis - adult |
422 |
422 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
442 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
110 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
186 |
$4K |
| D0274 |
Bitewings - four radiographic images |
182 |
182 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
50 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$1K |
| D0330 |
Panoramic radiographic image |
73 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$80.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$20.00 |