| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
492 |
486 |
$60K |
| D1110 |
Prophylaxis - adult |
736 |
735 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,061 |
1,059 |
$19K |
| D1120 |
Prophylaxis - child |
239 |
239 |
$7K |
| D1206 |
Topical application of fluoride varnish |
379 |
378 |
$6K |
| D0274 |
Bitewings - four radiographic images |
183 |
182 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
47 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$519.98 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$235.05 |