| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
105 |
101 |
$428K |
| D1351 |
Sealant - per tooth |
6,563 |
777 |
$175K |
| D8670 |
Periodic orthodontic treatment visit |
438 |
416 |
$107K |
| D1110 |
Prophylaxis - adult |
2,341 |
2,167 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
3,500 |
3,217 |
$85K |
| D1206 |
Topical application of fluoride varnish |
3,150 |
2,885 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,145 |
613 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
854 |
508 |
$55K |
| D0330 |
Panoramic radiographic image |
925 |
861 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,590 |
1,479 |
$47K |
| D0350 |
|
830 |
809 |
$41K |
| D1120 |
Prophylaxis - child |
1,462 |
1,361 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
501 |
207 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
189 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
614 |
579 |
$16K |
| D2331 |
|
197 |
134 |
$15K |
| D0340 |
|
219 |
219 |
$12K |
| D2335 |
|
129 |
92 |
$12K |
| D7250 |
|
94 |
58 |
$11K |
| D0272 |
Bitewings - two radiographic images |
423 |
395 |
$11K |
| D2330 |
|
190 |
87 |
$10K |
| D2722 |
|
19 |
15 |
$8K |
| D2332 |
|
75 |
61 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
470 |
$6K |
| D7111 |
|
74 |
52 |
$5K |
| D3320 |
|
18 |
16 |
$4K |
| D3310 |
|
21 |
15 |
$4K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
14 |
$4K |
| D8660 |
|
503 |
490 |
$4K |
| D2394 |
|
28 |
26 |
$3K |
| D8693 |
|
13 |
13 |
$2K |
| D4355 |
|
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
46 |
$382.33 |
| D1330 |
|
12 |
12 |
$167.16 |