| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
1,334 |
1,292 |
$97K |
| D1120 |
Prophylaxis - child |
1,668 |
1,645 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,599 |
2,561 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,045 |
2,017 |
$63K |
| D1110 |
Prophylaxis - adult |
681 |
671 |
$43K |
| D9248 |
|
154 |
147 |
$28K |
| D1351 |
Sealant - per tooth |
558 |
124 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
80 |
$17K |
| D0272 |
Bitewings - two radiographic images |
769 |
759 |
$12K |
| D1330 |
|
1,184 |
1,169 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
40 |
$7K |
| D0330 |
Panoramic radiographic image |
138 |
135 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$288.84 |
| D0240 |
|
13 |
13 |
$234.00 |