| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
24 |
24 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
563 |
$41K |
| D1120 |
Prophylaxis - child |
910 |
896 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
129 |
36 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
123 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,046 |
1,032 |
$29K |
| D9310 |
|
244 |
243 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
352 |
300 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
75 |
$14K |
| D0272 |
Bitewings - two radiographic images |
368 |
362 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
330 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
535 |
515 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
417 |
384 |
$7K |
| D0240 |
|
175 |
127 |
$7K |
| D8670 |
Periodic orthodontic treatment visit |
370 |
368 |
$4K |
| D1351 |
Sealant - per tooth |
81 |
28 |
$3K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$876.62 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$713.41 |