| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
2,725 |
2,620 |
$245K |
| D0120 |
Periodic oral evaluation - established patient |
2,188 |
2,177 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
433 |
341 |
$43K |
| D1120 |
Prophylaxis - child |
1,438 |
1,432 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,334 |
2,324 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
862 |
775 |
$35K |
| D1110 |
Prophylaxis - adult |
963 |
959 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
150 |
93 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
274 |
144 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
170 |
$15K |
| D0330 |
Panoramic radiographic image |
267 |
266 |
$15K |
| D1351 |
Sealant - per tooth |
553 |
195 |
$14K |
| D0272 |
Bitewings - two radiographic images |
691 |
691 |
$12K |
| D0274 |
Bitewings - four radiographic images |
399 |
396 |
$12K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
15 |
14 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
176 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
168 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
325 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
229 |
159 |
$3K |
| D2330 |
|
37 |
15 |
$2K |
| D2332 |
|
13 |
12 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
13 |
$1K |
| D0470 |
|
24 |
24 |
$975.84 |