| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,932 |
3,753 |
$158K |
| D8670 |
Periodic orthodontic treatment visit |
471 |
466 |
$111K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,932 |
3,753 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,368 |
3,216 |
$93K |
| D1351 |
Sealant - per tooth |
1,369 |
799 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
2,989 |
2,847 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,934 |
2,762 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
535 |
500 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
227 |
143 |
$14K |
| D0274 |
Bitewings - four radiographic images |
629 |
574 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
86 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
45 |
34 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
150 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
26 |
$2K |
| D2160 |
|
16 |
12 |
$986.85 |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$789.60 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$728.40 |