| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
1,343 |
1,221 |
$295K |
| D1206 |
Topical application of fluoride varnish |
1,768 |
1,741 |
$43K |
| D1120 |
Prophylaxis - child |
624 |
620 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,063 |
1,054 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
311 |
177 |
$27K |
| D1110 |
Prophylaxis - adult |
406 |
404 |
$25K |
| D0274 |
Bitewings - four radiographic images |
274 |
272 |
$11K |
| D8680 |
|
106 |
92 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
25 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$2K |
| D8703 |
|
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
40 |
$658.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$633.00 |
| D1999 |
|
48 |
46 |
$0.00 |
| D8999 |
|
12 |
12 |
$0.00 |