| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,982 |
1,521 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,169 |
474 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,130 |
802 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,549 |
858 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,401 |
1,394 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
1,767 |
1,720 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
960 |
953 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,007 |
999 |
$11K |
| D1120 |
Prophylaxis - child |
564 |
561 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
2,154 |
2,107 |
$8K |
| D1110 |
Prophylaxis - adult |
348 |
343 |
$7K |
| D0274 |
Bitewings - four radiographic images |
893 |
885 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
257 |
255 |
$5K |
| D2394 |
|
199 |
161 |
$4K |
| D1206 |
Topical application of fluoride varnish |
802 |
789 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,251 |
661 |
$3K |
| D0270 |
|
822 |
812 |
$2K |
| D1351 |
Sealant - per tooth |
85 |
24 |
$2K |
| D2331 |
|
80 |
55 |
$2K |
| D4341 |
|
111 |
38 |
$2K |
| D0330 |
Panoramic radiographic image |
162 |
158 |
$864.00 |
| D0603 |
|
259 |
257 |
$506.00 |
| D0602 |
|
204 |
202 |
$473.00 |
| D0272 |
Bitewings - two radiographic images |
49 |
48 |
$350.00 |
| D1999 |
|
27 |
25 |
$182.00 |
| D0240 |
|
73 |
36 |
$128.00 |
| D0601 |
|
67 |
67 |
$99.00 |
| D1330 |
|
1,525 |
1,482 |
$66.00 |
| D1320 |
|
64 |
64 |
$60.00 |
| D1310 |
|
1,226 |
1,186 |
$30.00 |
| D9995 |
|
118 |
117 |
$20.00 |
| D1354 |
|
51 |
12 |
$14.00 |
| D0600 |
|
111 |
109 |
$0.00 |