| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
5,868 |
5,838 |
$312K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,369 |
4,352 |
$271K |
| D1120 |
Prophylaxis - child |
5,318 |
5,266 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,861 |
1,346 |
$188K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,451 |
1,108 |
$130K |
| D0274 |
Bitewings - four radiographic images |
6,334 |
6,277 |
$129K |
| D0230 |
Intraoral - periapical each additional radiographic image |
31,209 |
8,321 |
$125K |
| D0210 |
Intraoral - complete series of radiographic images |
1,664 |
1,661 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,330 |
5,270 |
$59K |
| D1351 |
Sealant - per tooth |
2,416 |
629 |
$54K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
113 |
88 |
$53K |
| D4910 |
|
630 |
627 |
$47K |
| D4341 |
|
638 |
182 |
$44K |
| D8670 |
Periodic orthodontic treatment visit |
117 |
117 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
246 |
136 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
304 |
168 |
$24K |
| D2954 |
|
149 |
112 |
$16K |
| D7240 |
Removal of impacted tooth - completely bony |
62 |
25 |
$14K |
| D9220 |
|
56 |
56 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
220 |
88 |
$12K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$7K |
| D9430 |
|
219 |
211 |
$6K |
| D0272 |
Bitewings - two radiographic images |
527 |
521 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
172 |
172 |
$6K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
40 |
26 |
$5K |
| D9221 |
|
46 |
44 |
$5K |
| D4342 |
|
91 |
28 |
$4K |
| D9222 |
|
25 |
25 |
$3K |
| D0330 |
Panoramic radiographic image |
95 |
95 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
52 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
16 |
$170.00 |
| D0270 |
|
18 |
18 |
$90.00 |