| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
274 |
265 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
818 |
816 |
$15K |
| D1120 |
Prophylaxis - child |
456 |
456 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
989 |
985 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
975 |
971 |
$9K |
| D0274 |
Bitewings - four radiographic images |
280 |
280 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
458 |
458 |
$6K |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$1K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$1K |