| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,713 |
2,710 |
$365K |
| D1110 |
Prophylaxis - adult |
8,192 |
8,119 |
$280K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,155 |
11,923 |
$255K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,116 |
2,021 |
$252K |
| D0120 |
Periodic oral evaluation - established patient |
9,926 |
9,851 |
$227K |
| D0210 |
Intraoral - complete series of radiographic images |
4,311 |
4,287 |
$203K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,037 |
1,037 |
$171K |
| D4341 |
|
1,580 |
645 |
$157K |
| D0274 |
Bitewings - four radiographic images |
7,536 |
7,480 |
$148K |
| D1999 |
|
13,497 |
11,806 |
$127K |
| D1120 |
Prophylaxis - child |
3,937 |
3,926 |
$108K |
| D1351 |
Sealant - per tooth |
4,210 |
742 |
$108K |
| D2950 |
|
1,420 |
1,274 |
$107K |
| D0140 |
Limited oral evaluation - problem focused |
4,707 |
4,597 |
$103K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,298 |
479 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,721 |
3,706 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
780 |
585 |
$71K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
200 |
197 |
$69K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
202 |
162 |
$66K |
| D2332 |
|
473 |
320 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
5,685 |
5,598 |
$35K |
| D0330 |
Panoramic radiographic image |
1,201 |
1,199 |
$33K |
| D5110 |
|
39 |
39 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,150 |
3,110 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
218 |
153 |
$13K |
| D2335 |
|
81 |
53 |
$7K |
| D2330 |
|
75 |
53 |
$5K |
| D0272 |
Bitewings - two radiographic images |
196 |
195 |
$2K |
| D2160 |
|
30 |
25 |
$2K |
| D0180 |
|
37 |
37 |
$1K |
| D2140 |
|
24 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
35 |
34 |
$886.78 |
| D4355 |
|
42 |
42 |
$414.00 |
| D0240 |
|
18 |
14 |
$126.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
675 |
522 |
$0.00 |