| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
245 |
243 |
$8K |
| D1206 |
Topical application of fluoride varnish |
263 |
257 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
133 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
123 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
188 |
$2K |
| D0272 |
Bitewings - two radiographic images |
118 |
117 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
230 |
$1K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
41 |
30 |
$774.36 |
| D1351 |
Sealant - per tooth |
62 |
16 |
$636.39 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
77 |
76 |
$442.56 |
| D0603 |
|
42 |
40 |
$50.00 |
| D9630 |
|
76 |
75 |
$0.00 |
| D9215 |
|
20 |
20 |
$0.00 |