| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
486 |
429 |
$94K |
| D1120 |
Prophylaxis - child |
2,102 |
1,845 |
$73K |
| D1206 |
Topical application of fluoride varnish |
1,387 |
1,184 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,241 |
1,092 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
169 |
$12K |
| D1351 |
Sealant - per tooth |
177 |
71 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
290 |
279 |
$6K |
| D0274 |
Bitewings - four radiographic images |
382 |
339 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
44 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
83 |
$4K |
| D1110 |
Prophylaxis - adult |
135 |
128 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
151 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
73 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
308 |
278 |
$2K |
| D0272 |
Bitewings - two radiographic images |
132 |
119 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
141 |
$718.20 |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$565.00 |