| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
886 |
875 |
$123K |
| D1120 |
Prophylaxis - child |
2,126 |
2,110 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
432 |
125 |
$45K |
| D1206 |
Topical application of fluoride varnish |
2,905 |
2,888 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
2,405 |
2,389 |
$43K |
| D9920 |
|
441 |
436 |
$42K |
| T1015 |
Clinic visit/encounter, all-inclusive |
278 |
256 |
$34K |
| 92522 |
|
330 |
322 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
331 |
130 |
$21K |
| D1330 |
|
1,654 |
1,648 |
$20K |
| D1110 |
Prophylaxis - adult |
638 |
633 |
$18K |
| D1351 |
Sealant - per tooth |
877 |
241 |
$16K |
| 92524 |
|
169 |
163 |
$13K |
| 92507 |
Treatment of speech, language, voice, communication, and/or auditory processing disorder |
598 |
301 |
$13K |
| D1310 |
|
1,465 |
1,459 |
$13K |
| D0272 |
Bitewings - two radiographic images |
730 |
723 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
211 |
121 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
230 |
225 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
224 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
111 |
104 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
91 |
$4K |
| 92587 |
|
90 |
88 |
$4K |
| 92568 |
|
274 |
265 |
$3K |
| D0603 |
|
1,102 |
1,089 |
$3K |
| D0330 |
Panoramic radiographic image |
80 |
78 |
$2K |
| D9420 |
|
39 |
38 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$2K |
| D0240 |
|
104 |
99 |
$2K |
| 99215 |
Prolong outpt/office vis |
13 |
13 |
$1K |
| 92567 |
|
62 |
57 |
$739.80 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
14 |
14 |
$617.75 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
55 |
$255.60 |
| D0340 |
|
14 |
13 |
$253.50 |
| D1354 |
|
19 |
13 |
$220.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$210.75 |
| 92552 |
|
17 |
13 |
$142.40 |
| 92555 |
|
13 |
13 |
$105.03 |
| D1999 |
|
80 |
76 |
$84.00 |