| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
986 |
859 |
$45K |
| D1206 |
Topical application of fluoride varnish |
961 |
835 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
488 |
427 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
343 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
104 |
62 |
$9K |
| D0272 |
Bitewings - two radiographic images |
399 |
318 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
891 |
602 |
$4K |
| D1351 |
Sealant - per tooth |
228 |
50 |
$4K |
| D0274 |
Bitewings - four radiographic images |
182 |
155 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
196 |
163 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
621 |
590 |
$3K |
| D0603 |
|
527 |
442 |
$2K |
| D9630 |
|
131 |
109 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$398.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$112.64 |
| D9215 |
|
83 |
69 |
$0.00 |