| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
1,980 |
1,971 |
$569K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,360 |
4,358 |
$273K |
| D0120 |
Periodic oral evaluation - established patient |
3,871 |
3,871 |
$199K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,873 |
1,883 |
$193K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,512 |
779 |
$179K |
| D0210 |
Intraoral - complete series of radiographic images |
3,382 |
3,378 |
$159K |
| D1110 |
Prophylaxis - adult |
1,189 |
1,189 |
$103K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,211 |
4,877 |
$102K |
| D4341 |
|
1,467 |
605 |
$101K |
| D2140 |
|
1,836 |
1,170 |
$100K |
| D1120 |
Prophylaxis - child |
2,396 |
2,394 |
$86K |
| D0274 |
Bitewings - four radiographic images |
3,914 |
3,907 |
$82K |
| D0140 |
Limited oral evaluation - problem focused |
1,509 |
1,500 |
$51K |
| D0350 |
|
4,039 |
2,230 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
333 |
$33K |
| D2330 |
|
398 |
242 |
$31K |
| D2160 |
|
363 |
295 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,794 |
1,794 |
$27K |
| D4342 |
|
631 |
273 |
$26K |
| D4910 |
|
325 |
321 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,066 |
2,059 |
$21K |
| D0330 |
Panoramic radiographic image |
830 |
791 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
358 |
252 |
$19K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
13 |
13 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
40 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
54 |
$6K |
| D9430 |
|
154 |
154 |
$5K |
| D1351 |
Sealant - per tooth |
196 |
55 |
$5K |
| D0470 |
|
38 |
37 |
$3K |
| D2331 |
|
33 |
25 |
$3K |
| D0340 |
|
13 |
13 |
$650.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$432.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |
| D0270 |
|
28 |
28 |
$140.00 |
| D0601 |
|
35 |
35 |
$45.00 |
| D1330 |
|
629 |
629 |
$0.00 |