| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
1,832 |
1,819 |
$99K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
117 |
82 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,212 |
2,474 |
$54K |
| D1110 |
Prophylaxis - adult |
569 |
565 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
809 |
791 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,897 |
1,887 |
$37K |
| D1120 |
Prophylaxis - child |
1,064 |
1,057 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,449 |
2,436 |
$30K |
| D4910 |
|
393 |
388 |
$30K |
| D2954 |
|
156 |
119 |
$16K |
| D4341 |
|
197 |
65 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
190 |
78 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
234 |
229 |
$11K |
| D2931 |
|
51 |
38 |
$6K |
| D9430 |
|
193 |
186 |
$6K |
| D2140 |
|
75 |
42 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
324 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
13 |
$2K |
| D0350 |
|
225 |
122 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$960.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |