| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
1,376 |
1,041 |
$212K |
| D9920 |
|
3,966 |
3,888 |
$184K |
| D1110 |
Prophylaxis - adult |
2,674 |
2,670 |
$143K |
| D4355 |
|
670 |
667 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
523 |
291 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,563 |
2,558 |
$37K |
| D0274 |
Bitewings - four radiographic images |
839 |
835 |
$29K |
| D1351 |
Sealant - per tooth |
666 |
223 |
$19K |
| D2332 |
|
81 |
58 |
$9K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$5K |
| D2330 |
|
71 |
45 |
$5K |
| D1330 |
|
448 |
446 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
3,612 |
3,601 |
$2K |
| D1204 |
|
28 |
28 |
$0.00 |