| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,992 |
1,989 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,829 |
2,825 |
$70K |
| D0210 |
Intraoral - complete series of radiographic images |
731 |
729 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
144 |
$11K |
| D0274 |
Bitewings - four radiographic images |
425 |
425 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
442 |
442 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
147 |
$2K |