| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
2,739 |
2,622 |
$391K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
358 |
185 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
341 |
195 |
$5K |
| D8670 |
Periodic orthodontic treatment visit |
20 |
20 |
$580.00 |
| D1120 |
Prophylaxis - child |
1,318 |
1,317 |
$470.85 |
| D0220 |
Intraoral - periapical first radiographic image |
656 |
653 |
$291.85 |
| D0120 |
Periodic oral evaluation - established patient |
1,324 |
1,323 |
$232.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,259 |
1,253 |
$140.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
123 |
$110.00 |
| D0272 |
Bitewings - two radiographic images |
773 |
773 |
$108.35 |
| D1351 |
Sealant - per tooth |
464 |
132 |
$86.00 |
| D1354 |
|
262 |
78 |
$40.85 |
| D0140 |
Limited oral evaluation - problem focused |
290 |
290 |
$13.30 |
| D0603 |
|
1,216 |
1,216 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$0.00 |
| D9440 |
|
40 |
39 |
$0.00 |
| D1330 |
|
955 |
954 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
106 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$0.00 |
| D0330 |
Panoramic radiographic image |
315 |
315 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
90 |
89 |
$0.00 |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$0.00 |