| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
256 |
51 |
$7K |
| D1110 |
Prophylaxis - adult |
118 |
114 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
49 |
30 |
$4K |
| D1120 |
Prophylaxis - child |
90 |
89 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
119 |
$3K |
| D0274 |
Bitewings - four radiographic images |
96 |
90 |
$3K |
| D2140 |
|
42 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
119 |
118 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
61 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
63 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
23 |
22 |
$908.44 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
60 |
$735.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$694.38 |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
25 |
$488.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
22 |
$226.00 |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$64.52 |