| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
283 |
151 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
86 |
37 |
$7K |
| D1110 |
Prophylaxis - adult |
126 |
67 |
$6K |
| D1120 |
Prophylaxis - child |
159 |
85 |
$5K |
| D1206 |
Topical application of fluoride varnish |
286 |
153 |
$5K |
| D0272 |
Bitewings - two radiographic images |
215 |
114 |
$5K |
| D2140 |
|
62 |
28 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
113 |
63 |
$3K |
| D0602 |
|
213 |
111 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
14 |
$451.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$299.25 |
| D0601 |
|
42 |
25 |
$190.00 |