| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
174 |
174 |
$40K |
| D1120 |
Prophylaxis - child |
1,132 |
1,132 |
$36K |
| D1351 |
Sealant - per tooth |
643 |
158 |
$23K |
| D1110 |
Prophylaxis - adult |
518 |
518 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
868 |
868 |
$19K |
| D0274 |
Bitewings - four radiographic images |
840 |
840 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,302 |
1,301 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,109 |
1,109 |
$13K |
| D9990 |
|
607 |
576 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
534 |
534 |
$12K |
| D1206 |
Topical application of fluoride varnish |
504 |
504 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,096 |
1,085 |
$6K |
| D0340 |
|
85 |
85 |
$4K |
| D1320 |
|
386 |
386 |
$3K |
| D8660 |
|
103 |
102 |
$3K |
| D0272 |
Bitewings - two radiographic images |
126 |
126 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D0350 |
|
98 |
98 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$458.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$381.00 |