| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
243 |
238 |
$10K |
| D1206 |
Topical application of fluoride varnish |
446 |
435 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
232 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
101 |
84 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
102 |
$3K |
| D0274 |
Bitewings - four radiographic images |
116 |
115 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$999.52 |