| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0240 |
|
2,247 |
695 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,510 |
976 |
$40K |
| D1110 |
Prophylaxis - adult |
757 |
491 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,479 |
955 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,202 |
773 |
$28K |
| D1120 |
Prophylaxis - child |
653 |
402 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
229 |
130 |
$18K |
| D1351 |
Sealant - per tooth |
608 |
117 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
101 |
63 |
$14K |
| D2140 |
|
183 |
90 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
260 |
181 |
$7K |
| D0603 |
|
649 |
371 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
147 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
135 |
135 |
$2K |
| D0602 |
|
163 |
94 |
$815.00 |