| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
6,736 |
5,837 |
$552K |
| D8660 |
|
1,784 |
1,610 |
$313K |
| D1515 |
|
78 |
45 |
$25K |
| D0330 |
Panoramic radiographic image |
296 |
284 |
$18K |
| D9430 |
|
404 |
332 |
$18K |
| D1120 |
Prophylaxis - child |
300 |
300 |
$13K |
| D1206 |
Topical application of fluoride varnish |
257 |
257 |
$9K |
| D8680 |
|
57 |
48 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
12 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
305 |
$7K |
| D1310 |
|
186 |
122 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
36 |
$6K |
| D1330 |
|
186 |
122 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
44 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
30 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$3K |
| D9450 |
|
66 |
50 |
$3K |
| D1351 |
Sealant - per tooth |
89 |
34 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$3K |
| D9110 |
|
47 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
42 |
$1K |
| D0470 |
|
14 |
14 |
$896.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$694.00 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
44 |
$625.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$510.00 |
| D0240 |
|
13 |
13 |
$375.00 |