| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
183 |
54 |
$5K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
65 |
46 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
62 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$2K |
| D0272 |
Bitewings - two radiographic images |
101 |
101 |
$2K |
| D2160 |
|
21 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$320.00 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$190.00 |
| D1999 |
|
32 |
32 |
$0.00 |