| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,326 |
3,155 |
$131K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,548 |
3,375 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,220 |
3,064 |
$87K |
| D1351 |
Sealant - per tooth |
1,299 |
684 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,734 |
1,660 |
$25K |
| D4910 |
|
319 |
315 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
3,455 |
3,247 |
$18K |
| D4342 |
|
82 |
42 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,333 |
3,133 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,008 |
948 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
82 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
149 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$1K |