| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
1,782 |
1,779 |
$324K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
88 |
88 |
$84K |
| D1351 |
Sealant - per tooth |
417 |
86 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
51 |
$6K |
| D1120 |
Prophylaxis - child |
180 |
180 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
278 |
$5K |
| D8660 |
|
41 |
41 |
$5K |
| D1110 |
Prophylaxis - adult |
123 |
123 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
207 |
207 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
88 |
83 |
$4K |
| D0330 |
Panoramic radiographic image |
89 |
89 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$3K |
| D0272 |
Bitewings - two radiographic images |
173 |
173 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
99 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$256.00 |
| D1999 |
|
17 |
17 |
$0.00 |