| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
1,895 |
834 |
$208K |
| D1110 |
Prophylaxis - adult |
1,962 |
1,961 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,565 |
691 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,378 |
2,375 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,219 |
2,219 |
$50K |
| D9945 |
|
206 |
206 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,408 |
2,393 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,505 |
2,476 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
80 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
123 |
122 |
$2K |
| D9110 |
|
72 |
72 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$455.80 |