| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,979 |
2,528 |
$413K |
| D1110 |
Prophylaxis - adult |
951 |
951 |
$812.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,182 |
1,182 |
$496.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
249 |
$337.01 |
| D0330 |
Panoramic radiographic image |
431 |
431 |
$333.00 |
| D0274 |
Bitewings - four radiographic images |
654 |
654 |
$238.01 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
92 |
$180.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$176.00 |
| D0140 |
Limited oral evaluation - problem focused |
231 |
231 |
$168.00 |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
317 |
$133.01 |
| D1120 |
Prophylaxis - child |
203 |
203 |
$43.00 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$17.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$0.01 |
| D1999 |
|
870 |
768 |
$0.00 |
| D4910 |
|
13 |
13 |
$0.00 |
| D0603 |
|
61 |
61 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$0.00 |
| D0602 |
|
52 |
52 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |