| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8670 |
Periodic orthodontic treatment visit |
1,997 |
1,619 |
$354K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,254 |
482 |
$246K |
| D1120 |
Prophylaxis - child |
4,967 |
4,934 |
$245K |
| D1206 |
Topical application of fluoride varnish |
7,299 |
7,245 |
$185K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,206 |
532 |
$119K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
79 |
77 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
3,231 |
3,210 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,625 |
1,611 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
750 |
411 |
$87K |
| D0140 |
Limited oral evaluation - problem focused |
1,533 |
1,493 |
$69K |
| D1351 |
Sealant - per tooth |
1,198 |
430 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
2,297 |
2,217 |
$44K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
482 |
293 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,328 |
1,313 |
$39K |
| D1110 |
Prophylaxis - adult |
567 |
564 |
$35K |
| D0274 |
Bitewings - four radiographic images |
823 |
813 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,468 |
1,499 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
312 |
205 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,320 |
1,207 |
$27K |
| D1354 |
|
1,268 |
259 |
$18K |
| D0330 |
Panoramic radiographic image |
191 |
189 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
67 |
36 |
$7K |
| D8660 |
|
65 |
64 |
$7K |
| D2335 |
|
35 |
15 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$5K |
| D2140 |
|
21 |
12 |
$2K |
| D1330 |
|
160 |
158 |
$0.00 |