| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
6,767 |
6,556 |
$1.29M |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
1,066 |
997 |
$463K |
| D8660 |
|
2,549 |
2,527 |
$129K |
| D1120 |
Prophylaxis - child |
1,663 |
1,662 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
480 |
132 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,096 |
2,094 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,570 |
1,570 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
530 |
492 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
287 |
125 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
216 |
$19K |
| D2933 |
|
83 |
31 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
460 |
460 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
56 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
223 |
223 |
$11K |
| D0274 |
Bitewings - four radiographic images |
326 |
326 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
113 |
$9K |
| D1110 |
Prophylaxis - adult |
201 |
201 |
$8K |
| D0272 |
Bitewings - two radiographic images |
261 |
261 |
$5K |
| D1330 |
|
822 |
822 |
$4K |
| D1351 |
Sealant - per tooth |
132 |
42 |
$3K |
| D0240 |
|
140 |
140 |
$3K |
| D0602 |
|
358 |
358 |
$3K |
| D0603 |
|
355 |
355 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
144 |
$1K |
| D0340 |
|
14 |
14 |
$817.18 |
| D0470 |
|
14 |
14 |
$770.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$712.40 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$608.52 |
| D0601 |
|
53 |
53 |
$510.00 |
| D0350 |
|
14 |
14 |
$325.00 |
| D0270 |
|
16 |
16 |
$148.00 |