| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,162 |
2,161 |
$96K |
| D1206 |
Topical application of fluoride varnish |
1,994 |
1,990 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,177 |
2,174 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
994 |
938 |
$24K |
| D0272 |
Bitewings - two radiographic images |
790 |
790 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
84 |
53 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
663 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
399 |
397 |
$3K |
| D0602 |
|
303 |
303 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0603 |
|
203 |
203 |
$1K |
| D0601 |
|
158 |
156 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$715.00 |