| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,678 |
1,623 |
$67K |
| D8670 |
Periodic orthodontic treatment visit |
190 |
185 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,492 |
1,447 |
$41K |
| D1351 |
Sealant - per tooth |
636 |
288 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,015 |
980 |
$26K |
| D0274 |
Bitewings - four radiographic images |
589 |
562 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,594 |
1,535 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,536 |
1,482 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
124 |
$3K |
| D0272 |
Bitewings - two radiographic images |
238 |
232 |
$2K |