| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
5,950 |
5,627 |
$861K |
| D7140 |
Extraction, erupted tooth or exposed root |
368 |
195 |
$913.76 |
| D0330 |
Panoramic radiographic image |
384 |
384 |
$47.50 |
| D1351 |
Sealant - per tooth |
1,188 |
343 |
$40.85 |
| D0120 |
Periodic oral evaluation - established patient |
2,611 |
2,611 |
$34.44 |
| D0140 |
Limited oral evaluation - problem focused |
225 |
222 |
$28.98 |
| D0274 |
Bitewings - four radiographic images |
225 |
225 |
$0.00 |
| D1110 |
Prophylaxis - adult |
530 |
529 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,394 |
1,394 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
153 |
$0.00 |
| D1354 |
|
196 |
75 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
61 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
784 |
784 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
304 |
304 |
$0.00 |
| D9310 |
|
33 |
33 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,950 |
1,946 |
$0.00 |
| D1310 |
|
76 |
76 |
$0.00 |
| D1330 |
|
77 |
77 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
152 |
$0.00 |
| D9995 |
|
78 |
78 |
$0.00 |