| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
1,789 |
1,786 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
531 |
239 |
$67K |
| D1351 |
Sealant - per tooth |
2,134 |
568 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
524 |
223 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,384 |
1,384 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,497 |
1,496 |
$37K |
| D1352 |
|
148 |
46 |
$10K |
| D1206 |
Topical application of fluoride varnish |
324 |
322 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
35 |
$8K |
| D0191 |
|
480 |
480 |
$7K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$3K |
| D1354 |
|
93 |
35 |
$2K |
| D0240 |
|
82 |
41 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
17 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
48 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$625.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$404.00 |
| D0601 |
|
27 |
27 |
$0.00 |