| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
919 |
913 |
$68K |
| D1110 |
Prophylaxis - adult |
480 |
477 |
$43K |
| D8670 |
Periodic orthodontic treatment visit |
417 |
394 |
$28K |
| D1351 |
Sealant - per tooth |
418 |
113 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
133 |
84 |
$7K |
| D8660 |
|
380 |
339 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
47 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
45 |
$4K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
57 |
$678.94 |
| D0120 |
Periodic oral evaluation - established patient |
1,347 |
1,339 |
$476.61 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,071 |
1,056 |
$131.94 |
| D0274 |
Bitewings - four radiographic images |
459 |
456 |
$88.68 |
| D0220 |
Intraoral - periapical first radiographic image |
1,104 |
1,097 |
$85.00 |
| D0240 |
|
258 |
254 |
$53.44 |
| D1206 |
Topical application of fluoride varnish |
1,359 |
1,352 |
$32.84 |
| D3120 |
|
38 |
28 |
$32.84 |
| D0272 |
Bitewings - two radiographic images |
777 |
773 |
$13.44 |
| D1330 |
|
1,439 |
1,430 |
$6.00 |