| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
2,999 |
2,288 |
$244K |
| D1120 |
Prophylaxis - child |
7,174 |
5,503 |
$147K |
| D1351 |
Sealant - per tooth |
5,266 |
697 |
$109K |
| D1206 |
Topical application of fluoride varnish |
6,113 |
4,815 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,285 |
2,777 |
$86K |
| D0330 |
Panoramic radiographic image |
2,625 |
1,975 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,659 |
2,483 |
$67K |
| D0274 |
Bitewings - four radiographic images |
3,965 |
3,050 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,730 |
1,326 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
511 |
225 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
577 |
259 |
$31K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
462 |
52 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
585 |
153 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
446 |
223 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,137 |
770 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,244 |
861 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
531 |
313 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
67 |
13 |
$3K |
| D9310 |
|
69 |
28 |
$1K |
| D0340 |
|
48 |
31 |
$1K |
| D0470 |
|
24 |
18 |
$624.60 |
| D0350 |
|
24 |
19 |
$396.15 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$325.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
15 |
$237.60 |