| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
3,346 |
3,241 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
3,996 |
3,839 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
752 |
575 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
3,391 |
3,249 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,170 |
1,145 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,206 |
2,164 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
399 |
279 |
$31K |
| D0330 |
Panoramic radiographic image |
682 |
659 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,015 |
981 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,505 |
2,272 |
$30K |
| D1120 |
Prophylaxis - child |
916 |
893 |
$24K |
| 99199 |
Unlisted special service, procedure or report |
2,450 |
2,450 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
481 |
460 |
$16K |
| D0272 |
Bitewings - two radiographic images |
948 |
926 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
32 |
$4K |
| D1351 |
Sealant - per tooth |
130 |
38 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$2K |
| D4355 |
|
15 |
12 |
$768.84 |