| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
248 |
241 |
$35K |
| D1120 |
Prophylaxis - child |
826 |
822 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,068 |
1,034 |
$21K |
| D1351 |
Sealant - per tooth |
552 |
204 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
667 |
663 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
131 |
58 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
119 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
236 |
229 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
58 |
$7K |
| D0272 |
Bitewings - two radiographic images |
379 |
377 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
83 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
177 |
$4K |
| D9248 |
|
16 |
15 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
197 |
$2K |
| D0240 |
|
49 |
44 |
$1K |
| D9110 |
|
31 |
30 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$449.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
30 |
$432.20 |