| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,062 |
1,989 |
$292K |
| D7140 |
Extraction, erupted tooth or exposed root |
292 |
184 |
$6K |
| D9310 |
|
244 |
242 |
$6K |
| D0330 |
Panoramic radiographic image |
350 |
349 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
76 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
482 |
478 |
$703.77 |
| D0140 |
Limited oral evaluation - problem focused |
458 |
454 |
$630.82 |
| D1120 |
Prophylaxis - child |
373 |
373 |
$608.55 |
| D0120 |
Periodic oral evaluation - established patient |
334 |
334 |
$403.85 |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$243.99 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$188.88 |
| D0272 |
Bitewings - two radiographic images |
184 |
184 |
$148.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
307 |
$134.42 |
| D1206 |
Topical application of fluoride varnish |
326 |
326 |
$118.50 |
| D1351 |
Sealant - per tooth |
65 |
20 |
$86.00 |
| D0270 |
|
42 |
42 |
$13.30 |
| D1330 |
|
45 |
45 |
$0.00 |
| D1310 |
|
30 |
30 |
$0.00 |
| D9420 |
|
15 |
15 |
$0.00 |
| D0191 |
|
416 |
416 |
$0.00 |