| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
1,009 |
838 |
$140K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
69 |
$585.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
63 |
$160.00 |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$150.00 |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$80.00 |
| D0120 |
Periodic oral evaluation - established patient |
105 |
105 |
$58.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
16 |
$53.63 |
| D0140 |
Limited oral evaluation - problem focused |
115 |
115 |
$14.00 |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
117 |
$10.00 |
| D0191 |
|
83 |
81 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$0.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
76 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$0.00 |