| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
3,285 |
3,165 |
$242K |
| D1110 |
Prophylaxis - adult |
802 |
788 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,118 |
1,103 |
$32K |
| D0274 |
Bitewings - four radiographic images |
882 |
867 |
$19K |
| D1120 |
Prophylaxis - child |
446 |
440 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
301 |
$15K |
| D0330 |
Panoramic radiographic image |
372 |
366 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
671 |
665 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
50 |
$12K |
| D9310 |
|
203 |
197 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
125 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
84 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
199 |
$2K |
| D0272 |
Bitewings - two radiographic images |
104 |
104 |
$2K |
| D1330 |
|
82 |
82 |
$492.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$90.00 |