| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,628 |
1,918 |
$379K |
| D1120 |
Prophylaxis - child |
10,544 |
10,427 |
$315K |
| D0120 |
Periodic oral evaluation - established patient |
14,402 |
14,207 |
$302K |
| D1110 |
Prophylaxis - adult |
5,526 |
5,443 |
$251K |
| D0330 |
Panoramic radiographic image |
3,130 |
3,077 |
$153K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,918 |
8,918 |
$132K |
| D1206 |
Topical application of fluoride varnish |
7,032 |
6,821 |
$119K |
| D0274 |
Bitewings - four radiographic images |
3,103 |
3,039 |
$95K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
581 |
359 |
$89K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,354 |
3,057 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,480 |
1,015 |
$88K |
| D0272 |
Bitewings - two radiographic images |
4,793 |
4,746 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
4,287 |
4,085 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,822 |
1,791 |
$55K |
| D0602 |
|
5,608 |
5,548 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
1,658 |
1,624 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
768 |
489 |
$50K |
| D1351 |
Sealant - per tooth |
1,959 |
552 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,441 |
1,873 |
$19K |
| D0603 |
|
1,780 |
1,743 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
87 |
$14K |
| D0601 |
|
348 |
322 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
18 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
13 |
$2K |
| D2140 |
|
17 |
13 |
$845.85 |
| D9310 |
|
16 |
16 |
$780.32 |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$760.68 |