| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
449 |
442 |
$36K |
| D1110 |
Prophylaxis - adult |
661 |
649 |
$21K |
| D0330 |
Panoramic radiographic image |
299 |
296 |
$10K |
| D0350 |
|
451 |
445 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
354 |
349 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
357 |
$994.88 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$647.14 |
| D0274 |
Bitewings - four radiographic images |
545 |
534 |
$373.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
897 |
873 |
$266.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
584 |
574 |
$249.88 |
| D0220 |
Intraoral - periapical first radiographic image |
922 |
898 |
$157.02 |
| D1330 |
|
934 |
920 |
$67.80 |
| D1206 |
Topical application of fluoride varnish |
75 |
74 |
$14.95 |
| D4921 |
|
212 |
207 |
$0.00 |
| D1999 |
|
140 |
136 |
$0.00 |
| D1120 |
Prophylaxis - child |
27 |
26 |
$0.00 |
| D0190 |
|
171 |
167 |
$0.00 |
| D9910 |
|
19 |
12 |
$0.00 |
| D9630 |
|
119 |
118 |
$0.00 |