| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,424 |
2,423 |
$98K |
| D1351 |
Sealant - per tooth |
1,120 |
426 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,951 |
1,951 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,191 |
1,191 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,343 |
1,342 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
103 |
29 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,333 |
1,332 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,151 |
1,147 |
$16K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
56 |
54 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
396 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
81 |
$11K |
| D2335 |
|
42 |
13 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
678 |
677 |
$6K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$5K |
| D9222 |
|
54 |
54 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
13 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$1K |
| D1999 |
|
1,225 |
1,199 |
$0.00 |
| D0601 |
|
795 |
795 |
$0.00 |
| D1330 |
|
1,855 |
1,854 |
$0.00 |
| D0603 |
|
264 |
264 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |
| D1310 |
|
29 |
29 |
$0.00 |