| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
122 |
93 |
$12K |
| D8030 |
|
160 |
140 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
376 |
$9K |
| D1110 |
Prophylaxis - adult |
277 |
264 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
265 |
253 |
$4K |
| D0330 |
Panoramic radiographic image |
97 |
93 |
$4K |
| D1120 |
Prophylaxis - child |
175 |
166 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
115 |
111 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
69 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
135 |
$620.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
73 |
$380.00 |