| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
174 |
108 |
$23K |
| D1110 |
Prophylaxis - adult |
464 |
424 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
697 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
246 |
104 |
$13K |
| D0274 |
Bitewings - four radiographic images |
383 |
353 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
81 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
663 |
598 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
637 |
463 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
186 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
107 |
$4K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D1999 |
|
73 |
59 |
$0.00 |