| Code | Description | Claims | Beneficiaries | Total Paid |
| D8670 |
Periodic orthodontic treatment visit |
825 |
825 |
$347K |
| D7240 |
Removal of impacted tooth - completely bony |
786 |
255 |
$222K |
| D1110 |
Prophylaxis - adult |
4,122 |
4,120 |
$211K |
| D1206 |
Topical application of fluoride varnish |
8,082 |
8,080 |
$187K |
| D0120 |
Periodic oral evaluation - established patient |
7,785 |
7,782 |
$171K |
| D1120 |
Prophylaxis - child |
3,757 |
3,756 |
$138K |
| D8080 |
Comprehensive orthodontic treatment of the adolescent dentition |
116 |
116 |
$136K |
| D0274 |
Bitewings - four radiographic images |
2,727 |
2,726 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
852 |
551 |
$80K |
| D8660 |
|
363 |
362 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
5,773 |
5,760 |
$71K |
| D9630 |
|
3,113 |
3,113 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,441 |
4,867 |
$67K |
| D0272 |
Bitewings - two radiographic images |
1,169 |
1,169 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
578 |
558 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
281 |
205 |
$21K |
| D8680 |
|
45 |
45 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
118 |
56 |
$14K |
| D0330 |
Panoramic radiographic image |
206 |
206 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
351 |
$12K |
| D0340 |
|
124 |
124 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
424 |
423 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
66 |
44 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$8K |
| D1351 |
Sealant - per tooth |
216 |
68 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
175 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$4K |
| D9110 |
|
64 |
63 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
25 |
$3K |
| D8703 |
|
14 |
14 |
$2K |
| D8704 |
|
14 |
14 |
$2K |
| D2950 |
|
15 |
15 |
$2K |