| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
133 |
133 |
$35K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
220 |
36 |
$24K |
| D0340 |
|
255 |
254 |
$14K |
| D0330 |
Panoramic radiographic image |
297 |
296 |
$10K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
12 |
12 |
$8K |
| D8660 |
|
254 |
253 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$4K |
| D1120 |
Prophylaxis - child |
113 |
113 |
$4K |
| D0350 |
|
265 |
264 |
$3K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$941.26 |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$627.00 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$306.00 |
| D1999 |
|
94 |
90 |
$0.00 |