| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
1,033 |
973 |
$262K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,117 |
1,250 |
$194K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,375 |
867 |
$111K |
| D1110 |
Prophylaxis - adult |
2,224 |
2,176 |
$109K |
| D1120 |
Prophylaxis - child |
3,022 |
2,977 |
$96K |
| D1206 |
Topical application of fluoride varnish |
4,053 |
3,975 |
$85K |
| D0330 |
Panoramic radiographic image |
1,016 |
1,006 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,231 |
2,188 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
931 |
913 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,168 |
1,163 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,396 |
1,370 |
$34K |
| D1351 |
Sealant - per tooth |
1,285 |
465 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
210 |
161 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
644 |
617 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,541 |
1,481 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,101 |
879 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
700 |
700 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
66 |
$11K |
| D3120 |
|
44 |
26 |
$3K |
| D2331 |
|
17 |
12 |
$2K |
| D0240 |
|
82 |
60 |
$1K |
| D0603 |
|
384 |
378 |
$300.00 |
| D0602 |
|
222 |
219 |
$190.00 |
| D0210 |
Intraoral - complete series of radiographic images |
176 |
172 |
$6.50 |
| D1330 |
|
740 |
732 |
$0.00 |
| D1310 |
|
740 |
731 |
$0.00 |
| D0601 |
|
26 |
26 |
$0.00 |