| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
398 |
251 |
$85K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
454 |
73 |
$57K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
335 |
68 |
$16K |
| D1351 |
Sealant - per tooth |
340 |
131 |
$13K |
| D1206 |
Topical application of fluoride varnish |
537 |
499 |
$11K |
| D7240 |
Removal of impacted tooth - completely bony |
134 |
27 |
$9K |
| D0190 |
|
429 |
429 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
49 |
$3K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
54 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
67 |
48 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
47 |
45 |
$1K |
| D9222 |
|
57 |
29 |
$1K |
| D1353 |
|
31 |
19 |
$1K |
| D0170 |
|
25 |
14 |
$759.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$622.77 |
| D0240 |
|
12 |
12 |
$450.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$437.04 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$245.92 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$241.28 |