| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
691 |
690 |
$11K |
| D1110 |
Prophylaxis - adult |
395 |
392 |
$9K |
| D0274 |
Bitewings - four radiographic images |
353 |
353 |
$6K |
| D2140 |
|
113 |
69 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
184 |
99 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
124 |
$2K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$2K |
| D2160 |
|
15 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
149 |
128 |
$785.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
53 |
$713.18 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$129.88 |