| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
3,785 |
3,496 |
$598K |
| D1110 |
Prophylaxis - adult |
405 |
405 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
759 |
602 |
$648.00 |
| D0120 |
Periodic oral evaluation - established patient |
761 |
761 |
$609.00 |
| D0220 |
Intraoral - periapical first radiographic image |
910 |
894 |
$329.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
267 |
$247.80 |
| D0330 |
Panoramic radiographic image |
425 |
425 |
$240.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
299 |
243 |
$214.52 |
| D0140 |
Limited oral evaluation - problem focused |
924 |
924 |
$210.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
41 |
$206.70 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$203.00 |
| D0274 |
Bitewings - four radiographic images |
214 |
214 |
$174.00 |
| D9110 |
|
218 |
217 |
$171.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
221 |
$140.00 |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$116.00 |
| D2332 |
|
30 |
23 |
$105.30 |
| D0272 |
Bitewings - two radiographic images |
488 |
487 |
$34.00 |
| D0270 |
|
213 |
210 |
$14.00 |
| D2335 |
|
23 |
19 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
72 |
72 |
$0.00 |
| D0240 |
|
97 |
94 |
$0.00 |
| D2330 |
|
30 |
25 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
592 |
592 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
28 |
$0.00 |
| D1351 |
Sealant - per tooth |
439 |
174 |
$0.00 |
| D2331 |
|
34 |
27 |
$0.00 |
| D4341 |
|
34 |
14 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
83 |
58 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
144 |
103 |
$0.00 |
| D5110 |
|
34 |
27 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$0.00 |
| D1120 |
Prophylaxis - child |
471 |
471 |
$0.00 |
| D0251 |
|
14 |
14 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
143 |
141 |
$0.00 |
| D3320 |
|
22 |
19 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
21 |
16 |
$0.00 |