| Code | Description | Claims | Beneficiaries | Total Paid |
| D7140 |
Extraction, erupted tooth or exposed root |
7,959 |
1,738 |
$495K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,942 |
668 |
$229K |
| D1120 |
Prophylaxis - child |
6,851 |
6,818 |
$207K |
| D1206 |
Topical application of fluoride varnish |
12,802 |
12,733 |
$191K |
| D0120 |
Periodic oral evaluation - established patient |
7,972 |
7,928 |
$159K |
| D1110 |
Prophylaxis - adult |
3,447 |
3,420 |
$122K |
| D1351 |
Sealant - per tooth |
4,265 |
1,076 |
$101K |
| D1330 |
|
29,940 |
29,763 |
$94K |
| D1310 |
|
9,425 |
9,377 |
$92K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,258 |
1,238 |
$54K |
| D8670 |
Periodic orthodontic treatment visit |
226 |
196 |
$52K |
| 99203 |
Office or other outpatient visit for the evaluation and management of a new patient, low complexity |
991 |
965 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,939 |
2,923 |
$48K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
744 |
155 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,575 |
2,562 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
608 |
412 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
663 |
454 |
$34K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
122 |
120 |
$29K |
| D7240 |
Removal of impacted tooth - completely bony |
113 |
50 |
$22K |
| D9222 |
|
176 |
171 |
$21K |
| D0330 |
Panoramic radiographic image |
585 |
584 |
$21K |
| D0274 |
Bitewings - four radiographic images |
696 |
690 |
$19K |
| D0240 |
|
946 |
940 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
907 |
905 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,486 |
1,463 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
603 |
588 |
$11K |
| D1354 |
|
252 |
228 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
204 |
$10K |
| D1320 |
|
458 |
458 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
42 |
$5K |
| 70355 |
|
419 |
397 |
$4K |
| D7310 |
|
126 |
50 |
$3K |
| 99204 |
Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity |
39 |
38 |
$3K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
40 |
39 |
$2K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
59 |
58 |
$2K |
| 99215 |
Prolong outpt/office vis |
13 |
12 |
$850.75 |
| 70486 |
|
16 |
15 |
$754.62 |
| 99202 |
Office or other outpatient visit for the evaluation and management of a new patient, straightforward |
15 |
15 |
$513.70 |
| 99212 |
Office or other outpatient visit for the evaluation and management of an established patient, straightforward |
14 |
13 |
$354.38 |
| D0170 |
|
38 |
36 |
$309.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$19.29 |