| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
903 |
854 |
$106K |
| D1110 |
Prophylaxis - adult |
976 |
962 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,031 |
1,019 |
$21K |
| D0272 |
Bitewings - two radiographic images |
624 |
614 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
786 |
768 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
901 |
867 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
48 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
15 |
$967.40 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$955.40 |
| D9110 |
|
15 |
14 |
$411.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$226.72 |
| D1330 |
|
39 |
38 |
$215.40 |
| D1999 |
|
43 |
41 |
$0.00 |