| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
892 |
864 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,133 |
1,099 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,144 |
1,112 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
102 |
$21K |
| D0274 |
Bitewings - four radiographic images |
328 |
313 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
148 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
402 |
383 |
$6K |
| D4341 |
|
21 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
202 |
$3K |
| D0330 |
Panoramic radiographic image |
31 |
30 |
$2K |