| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
1,255 |
1,245 |
$507K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
149 |
146 |
$182K |
| D1110 |
Prophylaxis - adult |
3,311 |
3,290 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
5,164 |
5,146 |
$117K |
| D1206 |
Topical application of fluoride varnish |
4,207 |
4,181 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,199 |
799 |
$78K |
| D1120 |
Prophylaxis - child |
2,178 |
2,176 |
$65K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
611 |
273 |
$59K |
| D9920 |
|
457 |
442 |
$59K |
| D1351 |
Sealant - per tooth |
2,087 |
450 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,483 |
1,477 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
782 |
586 |
$41K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
115 |
68 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
559 |
261 |
$36K |
| D7240 |
Removal of impacted tooth - completely bony |
85 |
32 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
494 |
482 |
$22K |
| D1330 |
|
1,741 |
1,733 |
$20K |
| D1310 |
|
1,654 |
1,651 |
$19K |
| D8660 |
|
327 |
327 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
220 |
160 |
$16K |
| D0272 |
Bitewings - two radiographic images |
927 |
923 |
$15K |
| D0330 |
Panoramic radiographic image |
278 |
278 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,202 |
1,191 |
$10K |
| D9222 |
|
71 |
68 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
375 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
962 |
606 |
$9K |
| 99243 |
|
128 |
124 |
$9K |
| D2332 |
|
78 |
43 |
$6K |
| 70355 |
|
194 |
192 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
24 |
$2K |
| D8680 |
|
12 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
14 |
$2K |
| D2330 |
|
19 |
13 |
$950.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$595.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$318.24 |