| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
827 |
745 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
953 |
860 |
$9K |
| D1206 |
Topical application of fluoride varnish |
240 |
228 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
783 |
693 |
$4K |
| D0272 |
Bitewings - two radiographic images |
131 |
118 |
$322.53 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
186 |
168 |
$216.65 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$169.80 |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
14 |
$0.00 |
| D1351 |
Sealant - per tooth |
225 |
58 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
40 |
$0.00 |
| D0240 |
|
86 |
40 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
61 |
54 |
$0.00 |
| D9248 |
|
13 |
13 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
46 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
25 |
$0.00 |