| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,433 |
5,223 |
$222K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,330 |
5,121 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,843 |
4,654 |
$135K |
| D1351 |
Sealant - per tooth |
1,862 |
917 |
$128K |
| D8670 |
Periodic orthodontic treatment visit |
214 |
194 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,996 |
1,918 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
544 |
512 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
103 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
17 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
178 |
$1K |
| D0272 |
Bitewings - two radiographic images |
108 |
104 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
170 |
$761.61 |