| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
3,914 |
3,739 |
$565K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
38 |
29 |
$551.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
51 |
$209.00 |
| D1351 |
Sealant - per tooth |
842 |
268 |
$204.25 |
| D1206 |
Topical application of fluoride varnish |
1,126 |
1,122 |
$171.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
94 |
$165.30 |
| D1120 |
Prophylaxis - child |
2,055 |
2,055 |
$122.55 |
| D0220 |
Intraoral - periapical first radiographic image |
542 |
537 |
$93.10 |
| D0120 |
Periodic oral evaluation - established patient |
1,958 |
1,958 |
$82.65 |
| D0272 |
Bitewings - two radiographic images |
1,328 |
1,328 |
$32.30 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
202 |
188 |
$0.00 |
| D0330 |
Panoramic radiographic image |
264 |
264 |
$0.00 |
| D0191 |
|
234 |
234 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$0.00 |
| D1354 |
|
59 |
15 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,078 |
1,076 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
175 |
$0.00 |
| D0240 |
|
13 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
27 |
$0.00 |