| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
2,074 |
2,043 |
$466K |
| D1120 |
Prophylaxis - child |
3,743 |
3,743 |
$129K |
| D1351 |
Sealant - per tooth |
2,254 |
731 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,890 |
2,890 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,168 |
862 |
$62K |
| D1110 |
Prophylaxis - adult |
1,021 |
1,021 |
$48K |
| D8660 |
|
1,462 |
1,458 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,650 |
1,650 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,334 |
3,334 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,495 |
1,494 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,348 |
2,348 |
$32K |
| D0340 |
|
799 |
799 |
$31K |
| D0330 |
Panoramic radiographic image |
1,005 |
1,005 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
790 |
553 |
$29K |
| D0470 |
|
969 |
969 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
361 |
210 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,250 |
2,236 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
540 |
392 |
$18K |
| D9990 |
|
773 |
715 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,816 |
1,813 |
$12K |
| D0274 |
Bitewings - four radiographic images |
496 |
496 |
$12K |
| D0350 |
|
990 |
990 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
216 |
216 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
42 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
103 |
95 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
95 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
21 |
$266.26 |