| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
105 |
97 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
29 |
$4K |
| D1110 |
Prophylaxis - adult |
99 |
99 |
$3K |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$869.02 |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
94 |
$854.21 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$605.01 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
34 |
$246.00 |
| D1330 |
|
41 |
41 |
$200.00 |
| D0601 |
|
12 |
12 |
$110.00 |