| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
735 |
698 |
$79K |
| D1110 |
Prophylaxis - adult |
1,260 |
1,249 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,587 |
1,577 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,523 |
1,510 |
$39K |
| D1120 |
Prophylaxis - child |
652 |
652 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
450 |
450 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
32 |
$7K |
| D0272 |
Bitewings - two radiographic images |
170 |
170 |
$5K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$315.64 |