| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
241 |
241 |
$26K |
| D8660 |
|
103 |
103 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
61 |
$7K |
| D1351 |
Sealant - per tooth |
276 |
56 |
$6K |
| D0330 |
Panoramic radiographic image |
149 |
149 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
12 |
$5K |
| D1110 |
Prophylaxis - adult |
121 |
121 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
193 |
$4K |
| D0274 |
Bitewings - four radiographic images |
127 |
127 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
40 |
$4K |
| D9110 |
|
86 |
85 |
$3K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$2K |
| D0272 |
Bitewings - two radiographic images |
139 |
139 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
19 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
156 |
$1K |
| D1999 |
|
68 |
68 |
$0.00 |