| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
866 |
861 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,006 |
1,003 |
$27K |
| D1351 |
Sealant - per tooth |
780 |
219 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,073 |
1,068 |
$19K |
| D1110 |
Prophylaxis - adult |
271 |
269 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
69 |
$7K |
| D0272 |
Bitewings - two radiographic images |
343 |
340 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
120 |
106 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
76 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
204 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
13 |
$133.00 |