| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
261 |
246 |
$32K |
| D1351 |
Sealant - per tooth |
859 |
169 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
233 |
108 |
$23K |
| D1206 |
Topical application of fluoride varnish |
984 |
967 |
$19K |
| D1120 |
Prophylaxis - child |
585 |
582 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
118 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
118 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
139 |
73 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
181 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
371 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
319 |
$7K |
| D0272 |
Bitewings - two radiographic images |
224 |
223 |
$4K |
| D1110 |
Prophylaxis - adult |
87 |
87 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
84 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
230 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
167 |
$1K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$543.00 |
| D1310 |
|
36 |
36 |
$426.34 |
| D1354 |
|
23 |
14 |
$290.00 |