| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
266 |
261 |
$32K |
| D1120 |
Prophylaxis - child |
717 |
713 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,021 |
1,017 |
$18K |
| D1351 |
Sealant - per tooth |
755 |
159 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
712 |
708 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
90 |
24 |
$9K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$5K |
| D0272 |
Bitewings - two radiographic images |
189 |
188 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
30 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
99 |
$2K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
19 |
$916.52 |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
73 |
$584.00 |