| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,576 |
1,454 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,456 |
1,336 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,143 |
1,048 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
394 |
$12K |
| D1351 |
Sealant - per tooth |
378 |
81 |
$9K |
| D0272 |
Bitewings - two radiographic images |
434 |
395 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
43 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
27 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
226 |
191 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$989.86 |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
71 |
$908.91 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$541.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
17 |
$215.46 |