| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
1,658 |
1,409 |
$233K |
| T1015 |
Clinic visit/encounter, all-inclusive |
97 |
64 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
41 |
$332.00 |
| D1110 |
Prophylaxis - adult |
286 |
286 |
$313.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
186 |
87 |
$240.00 |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$87.00 |
| D0330 |
Panoramic radiographic image |
120 |
119 |
$80.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$58.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
41 |
$55.00 |
| D0220 |
Intraoral - periapical first radiographic image |
165 |
164 |
$24.00 |
| D0140 |
Limited oral evaluation - problem focused |
188 |
188 |
$14.00 |
| D0191 |
|
146 |
146 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
244 |
210 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
50 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |