| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
1,279 |
414 |
$138K |
| D2335 |
|
954 |
291 |
$109K |
| D1110 |
Prophylaxis - adult |
526 |
520 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
715 |
711 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
40 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
151 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
222 |
221 |
$2K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
73 |
$296.85 |