| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
442 |
371 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
231 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
147 |
$3K |
| D1120 |
Prophylaxis - child |
88 |
86 |
$3K |
| D1206 |
Topical application of fluoride varnish |
154 |
151 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
127 |
$942.15 |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$854.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$793.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
69 |
$523.73 |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$400.87 |
| D9994 |
|
113 |
113 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$0.00 |