| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
391 |
391 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
439 |
439 |
$8K |
| D0272 |
Bitewings - two radiographic images |
306 |
304 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
174 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
221 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
107 |
101 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D2140 |
|
31 |
17 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$1K |
| D0240 |
|
63 |
50 |
$704.54 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
32 |
$358.51 |