| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
689 |
668 |
$55K |
| D1351 |
Sealant - per tooth |
1,634 |
169 |
$38K |
| D1120 |
Prophylaxis - child |
694 |
673 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
31 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
28 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
315 |
304 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
86 |
77 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
583 |
553 |
$572.60 |
| D2140 |
|
15 |
13 |
$437.69 |
| D1206 |
Topical application of fluoride varnish |
771 |
744 |
$319.03 |
| D1110 |
Prophylaxis - adult |
48 |
43 |
$175.48 |
| D0330 |
Panoramic radiographic image |
31 |
28 |
$158.27 |
| D0274 |
Bitewings - four radiographic images |
198 |
182 |
$155.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
528 |
504 |
$67.38 |