| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,352 |
1,578 |
$134K |
| D1120 |
Prophylaxis - child |
2,758 |
2,631 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,367 |
3,213 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,920 |
3,728 |
$68K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
463 |
198 |
$56K |
| D1110 |
Prophylaxis - adult |
989 |
941 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,934 |
1,848 |
$40K |
| D0274 |
Bitewings - four radiographic images |
862 |
818 |
$25K |
| D0330 |
Panoramic radiographic image |
533 |
498 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
546 |
495 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
162 |
117 |
$10K |
| D2140 |
|
104 |
78 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
162 |
$5K |
| D0240 |
|
158 |
141 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$811.94 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$228.00 |