| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
473 |
202 |
$19K |
| D1120 |
Prophylaxis - child |
860 |
723 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,227 |
1,032 |
$16K |
| D1110 |
Prophylaxis - adult |
424 |
350 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
629 |
457 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
799 |
684 |
$9K |
| D0272 |
Bitewings - two radiographic images |
680 |
579 |
$8K |
| D0274 |
Bitewings - four radiographic images |
390 |
317 |
$5K |
| D1351 |
Sealant - per tooth |
405 |
73 |
$5K |
| D1206 |
Topical application of fluoride varnish |
304 |
246 |
$3K |
| D2140 |
|
24 |
15 |
$912.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$848.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$506.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$441.00 |