| Code | Description | Claims | Beneficiaries | Total Paid |
| D7140 |
Extraction, erupted tooth or exposed root |
1,951 |
604 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
865 |
420 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
1,083 |
859 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
892 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
368 |
205 |
$20K |
| D1110 |
Prophylaxis - adult |
529 |
477 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
923 |
827 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
205 |
135 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
424 |
379 |
$10K |
| D0274 |
Bitewings - four radiographic images |
415 |
373 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
331 |
173 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,276 |
503 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
766 |
674 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
278 |
$4K |
| D1351 |
Sealant - per tooth |
318 |
44 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
74 |
58 |
$1K |
| D2332 |
|
19 |
12 |
$669.48 |
| D2335 |
|
21 |
13 |
$464.22 |
| D2394 |
|
26 |
14 |
$344.03 |
| D0272 |
Bitewings - two radiographic images |
23 |
16 |
$248.10 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$30.95 |