| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,328 |
1,270 |
$33K |
| D1120 |
Prophylaxis - child |
741 |
704 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
223 |
106 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
407 |
355 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
512 |
512 |
$15K |
| D0274 |
Bitewings - four radiographic images |
262 |
247 |
$11K |
| D1110 |
Prophylaxis - adult |
173 |
163 |
$10K |
| D2140 |
|
131 |
64 |
$10K |
| D0272 |
Bitewings - two radiographic images |
196 |
178 |
$6K |
| D1351 |
Sealant - per tooth |
78 |
12 |
$3K |
| D0603 |
|
264 |
221 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
13 |
$679.36 |
| D1330 |
|
21 |
14 |
$525.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$402.39 |