| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
836 |
836 |
$177K |
| D1110 |
Prophylaxis - adult |
2,444 |
2,432 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
3,552 |
3,535 |
$116K |
| D1206 |
Topical application of fluoride varnish |
1,837 |
1,823 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,191 |
1,187 |
$46K |
| D1120 |
Prophylaxis - child |
1,100 |
1,094 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
122 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
480 |
468 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
92 |
$9K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$3K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
24 |
$2K |
| D9410 |
|
23 |
23 |
$879.12 |