| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
193 |
193 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
75 |
$9K |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
17 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
33 |
33 |
$878.60 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$392.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$224.14 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
31 |
$168.00 |