| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
1,187 |
1,145 |
$170K |
| D1120 |
Prophylaxis - child |
646 |
646 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
853 |
853 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
84 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
62 |
38 |
$7K |
| D0274 |
Bitewings - four radiographic images |
326 |
326 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
62 |
38 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
337 |
335 |
$5K |
| D1206 |
Topical application of fluoride varnish |
298 |
298 |
$4K |
| D1110 |
Prophylaxis - adult |
183 |
183 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
71 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
65 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
263 |
$3K |
| D1351 |
Sealant - per tooth |
216 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
274 |
274 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
189 |
189 |
$731.50 |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
197 |
$713.21 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
27 |
$712.50 |
| D9310 |
|
24 |
24 |
$681.05 |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
13 |
13 |
$288.80 |
| D0140 |
Limited oral evaluation - problem focused |
137 |
137 |
$0.00 |