| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2140 |
|
270 |
134 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
682 |
546 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
518 |
$4K |
| D1120 |
Prophylaxis - child |
459 |
374 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
171 |
70 |
$2K |
| D1110 |
Prophylaxis - adult |
112 |
88 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
99 |
71 |
$1K |
| D0272 |
Bitewings - two radiographic images |
117 |
99 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$505.75 |
| D9248 |
|
176 |
149 |
$423.50 |
| D1351 |
Sealant - per tooth |
63 |
15 |
$0.00 |