| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
4,064 |
3,882 |
$589K |
| D1120 |
Prophylaxis - child |
1,852 |
1,851 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
382 |
257 |
$2K |
| D0272 |
Bitewings - two radiographic images |
778 |
778 |
$553.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
265 |
$525.05 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,771 |
1,771 |
$485.00 |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
575 |
$463.45 |
| D7140 |
Extraction, erupted tooth or exposed root |
342 |
246 |
$418.00 |
| D0330 |
Panoramic radiographic image |
723 |
723 |
$396.50 |
| D0120 |
Periodic oral evaluation - established patient |
1,990 |
1,988 |
$348.05 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
138 |
$265.65 |
| D0140 |
Limited oral evaluation - problem focused |
283 |
283 |
$143.80 |
| D0274 |
Bitewings - four radiographic images |
503 |
503 |
$121.00 |
| D1110 |
Prophylaxis - adult |
483 |
483 |
$90.00 |
| D1351 |
Sealant - per tooth |
128 |
55 |
$81.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
702 |
701 |
$77.00 |
| D1206 |
Topical application of fluoride varnish |
289 |
289 |
$65.00 |
| D0603 |
|
173 |
173 |
$0.00 |
| D1330 |
|
577 |
577 |
$0.00 |
| D1310 |
|
380 |
380 |
$0.00 |
| D0601 |
|
108 |
108 |
$0.00 |
| D0602 |
|
42 |
42 |
$0.00 |
| D9995 |
|
26 |
24 |
$0.00 |