| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,514 |
1,831 |
$233K |
| D1120 |
Prophylaxis - child |
7,561 |
7,295 |
$192K |
| D0120 |
Periodic oral evaluation - established patient |
8,434 |
8,068 |
$176K |
| D1110 |
Prophylaxis - adult |
4,333 |
4,217 |
$167K |
| D1351 |
Sealant - per tooth |
7,819 |
1,878 |
$146K |
| D1206 |
Topical application of fluoride varnish |
11,592 |
11,205 |
$142K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,290 |
524 |
$132K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,084 |
4,007 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,220 |
1,331 |
$108K |
| D0210 |
Intraoral - complete series of radiographic images |
1,486 |
1,469 |
$95K |
| D0272 |
Bitewings - two radiographic images |
6,121 |
5,913 |
$93K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,093 |
3,659 |
$77K |
| D0274 |
Bitewings - four radiographic images |
3,418 |
3,357 |
$61K |
| D0145 |
Oral evaluation for a patient under three years of age |
732 |
730 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
5,996 |
5,714 |
$54K |
| D0330 |
Panoramic radiographic image |
2,921 |
2,854 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,777 |
4,103 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
334 |
193 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
792 |
757 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
128 |
45 |
$13K |
| D0603 |
|
11,151 |
10,916 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
243 |
173 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
68 |
24 |
$3K |
| D2140 |
|
20 |
12 |
$1K |
| D2332 |
|
16 |
12 |
$1K |
| D0270 |
|
317 |
313 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
13 |
$797.50 |
| D0602 |
|
916 |
899 |
$655.02 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
33 |
$357.54 |
| D0350 |
|
57 |
52 |
$321.65 |
| D0601 |
|
130 |
130 |
$310.00 |
| D1999 |
|
494 |
449 |
$0.00 |