| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
342 |
$22K |
| D1120 |
Prophylaxis - child |
343 |
341 |
$17K |
| D1351 |
Sealant - per tooth |
260 |
71 |
$10K |
| D1206 |
Topical application of fluoride varnish |
488 |
487 |
$10K |
| D1310 |
|
195 |
195 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
173 |
173 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
108 |
54 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,210 |
233 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
109 |
100 |
$4K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$4K |
| D4341 |
|
56 |
16 |
$4K |
| D1320 |
|
219 |
218 |
$3K |
| D0603 |
|
189 |
189 |
$3K |
| D0350 |
|
230 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
126 |
$2K |
| D2140 |
|
24 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$840.00 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$540.00 |