| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,223 |
2,833 |
$477K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,531 |
2,843 |
$398K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,035 |
1,698 |
$213K |
| D1120 |
Prophylaxis - child |
4,581 |
4,572 |
$181K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,618 |
1,067 |
$168K |
| D1110 |
Prophylaxis - adult |
4,197 |
4,143 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
6,252 |
6,221 |
$151K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,081 |
4,039 |
$136K |
| D0210 |
Intraoral - complete series of radiographic images |
2,666 |
2,625 |
$122K |
| D1206 |
Topical application of fluoride varnish |
4,445 |
4,436 |
$110K |
| D0274 |
Bitewings - four radiographic images |
2,572 |
2,557 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
2,646 |
2,620 |
$38K |
| D1351 |
Sealant - per tooth |
1,086 |
189 |
$33K |
| D2332 |
|
269 |
152 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
842 |
825 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,925 |
1,623 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
24 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
131 |
81 |
$15K |
| D2330 |
|
220 |
125 |
$14K |
| D0272 |
Bitewings - two radiographic images |
593 |
592 |
$14K |
| D2950 |
|
99 |
88 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
418 |
418 |
$10K |
| D2331 |
|
121 |
82 |
$8K |
| D2335 |
|
72 |
31 |
$8K |
| D3320 |
|
12 |
12 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
56 |
56 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
12 |
$895.84 |
| D2140 |
|
25 |
16 |
$836.73 |