| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
446 |
421 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
571 |
535 |
$14K |
| D2140 |
|
220 |
108 |
$14K |
| D0272 |
Bitewings - two radiographic images |
406 |
383 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
102 |
58 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
407 |
383 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
279 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
301 |
278 |
$4K |
| D1206 |
Topical application of fluoride varnish |
83 |
80 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
24 |
$691.60 |
| D1120 |
Prophylaxis - child |
19 |
17 |
$567.60 |
| D0601 |
|
20 |
20 |
$100.00 |
| D0603 |
|
15 |
12 |
$45.00 |