| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
6,424 |
6,301 |
$355K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,792 |
1,253 |
$334K |
| D0120 |
Periodic oral evaluation - established patient |
5,670 |
5,552 |
$212K |
| D1206 |
Topical application of fluoride varnish |
7,189 |
7,052 |
$198K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,623 |
997 |
$162K |
| D1110 |
Prophylaxis - adult |
1,680 |
1,636 |
$112K |
| D1351 |
Sealant - per tooth |
3,184 |
894 |
$109K |
| D0330 |
Panoramic radiographic image |
1,571 |
1,552 |
$107K |
| D7140 |
Extraction, erupted tooth or exposed root |
874 |
484 |
$94K |
| D0272 |
Bitewings - two radiographic images |
3,206 |
3,144 |
$92K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,585 |
1,569 |
$88K |
| D0220 |
Intraoral - periapical first radiographic image |
3,868 |
3,712 |
$68K |
| D0274 |
Bitewings - four radiographic images |
1,590 |
1,554 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,159 |
2,701 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,463 |
1,392 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
260 |
119 |
$45K |
| D1354 |
|
1,366 |
590 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
827 |
815 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
684 |
655 |
$33K |
| D9248 |
|
314 |
306 |
$32K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
112 |
52 |
$13K |
| D2332 |
|
19 |
12 |
$3K |
| D0603 |
|
6,660 |
5,863 |
$0.00 |
| D0602 |
|
24 |
12 |
$0.00 |