| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
326 |
50 |
$6K |
| D1120 |
Prophylaxis - child |
110 |
97 |
$5K |
| D1206 |
Topical application of fluoride varnish |
105 |
95 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
38 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
86 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
70 |
$2K |
| D1354 |
|
138 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
72 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
99 |
$836.38 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
75 |
48 |
$774.48 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$296.94 |
| D9215 |
|
88 |
55 |
$282.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
16 |
$153.60 |