| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,067 |
1,986 |
$298K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
297 |
190 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
249 |
149 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
417 |
$469.56 |
| D0330 |
Panoramic radiographic image |
461 |
460 |
$451.30 |
| D0140 |
Limited oral evaluation - problem focused |
454 |
453 |
$320.73 |
| D1120 |
Prophylaxis - child |
303 |
303 |
$241.55 |
| D0120 |
Periodic oral evaluation - established patient |
429 |
429 |
$190.20 |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$87.00 |
| D0272 |
Bitewings - two radiographic images |
126 |
126 |
$76.55 |
| D1110 |
Prophylaxis - adult |
185 |
185 |
$58.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
123 |
$0.00 |
| D9420 |
|
13 |
13 |
$0.00 |
| D1351 |
Sealant - per tooth |
40 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
27 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$0.00 |