| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,062 |
305 |
$25K |
| D1120 |
Prophylaxis - child |
686 |
682 |
$20K |
| D1206 |
Topical application of fluoride varnish |
943 |
940 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
759 |
756 |
$16K |
| D1110 |
Prophylaxis - adult |
259 |
258 |
$10K |
| D0272 |
Bitewings - two radiographic images |
510 |
507 |
$10K |
| D2140 |
|
156 |
108 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
371 |
340 |
$7K |
| D0274 |
Bitewings - four radiographic images |
240 |
240 |
$7K |
| D0330 |
Panoramic radiographic image |
140 |
140 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
27 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
72 |
54 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$3K |
| D0240 |
|
130 |
123 |
$2K |
| D1310 |
|
25 |
25 |
$0.00 |
| D1330 |
|
25 |
25 |
$0.00 |
| D0603 |
|
25 |
25 |
$0.00 |