| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
4,630 |
4,626 |
$241K |
| D1120 |
Prophylaxis - child |
5,069 |
5,053 |
$186K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,003 |
305 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,145 |
465 |
$76K |
| D1206 |
Topical application of fluoride varnish |
5,380 |
5,359 |
$68K |
| D1351 |
Sealant - per tooth |
2,383 |
597 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,871 |
3,195 |
$53K |
| D1310 |
|
1,071 |
1,069 |
$48K |
| D9993 |
|
680 |
680 |
$42K |
| D9920 |
|
330 |
326 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
722 |
243 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,211 |
1,209 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
404 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,621 |
1,544 |
$19K |
| D2330 |
|
233 |
68 |
$17K |
| D0603 |
|
1,049 |
1,048 |
$16K |
| D9430 |
|
433 |
425 |
$14K |
| D0272 |
Bitewings - two radiographic images |
941 |
939 |
$11K |
| D1352 |
|
281 |
73 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
26 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
31 |
31 |
$2K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$560.00 |