| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
8,089 |
3,409 |
$588K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,569 |
1,439 |
$365K |
| D1351 |
Sealant - per tooth |
16,205 |
3,266 |
$307K |
| D1120 |
Prophylaxis - child |
10,926 |
10,874 |
$276K |
| D0145 |
Oral evaluation for a patient under three years of age |
3,087 |
3,068 |
$274K |
| D0120 |
Periodic oral evaluation - established patient |
12,386 |
12,324 |
$263K |
| D1110 |
Prophylaxis - adult |
6,455 |
6,421 |
$248K |
| D0274 |
Bitewings - four radiographic images |
7,983 |
7,944 |
$163K |
| D1208 |
Topical application of fluoride, excluding varnish |
15,698 |
15,618 |
$159K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,233 |
5,197 |
$136K |
| D0210 |
Intraoral - complete series of radiographic images |
1,680 |
1,679 |
$106K |
| D0272 |
Bitewings - two radiographic images |
7,199 |
7,162 |
$98K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,126 |
4,512 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,765 |
7,459 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,553 |
1,023 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
9,537 |
9,435 |
$74K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
789 |
482 |
$48K |
| D0330 |
Panoramic radiographic image |
4,266 |
4,242 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
537 |
362 |
$41K |
| D7240 |
Removal of impacted tooth - completely bony |
176 |
56 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
426 |
285 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,479 |
1,478 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
920 |
913 |
$15K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
13 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
53 |
30 |
$3K |
| D2790 |
|
15 |
12 |
$3K |
| D2950 |
|
29 |
27 |
$856.69 |
| D0270 |
|
60 |
60 |
$186.80 |
| D0603 |
|
17,286 |
17,183 |
$45.02 |
| D0602 |
|
3,032 |
3,029 |
$9.00 |
| D0601 |
|
199 |
199 |
$0.00 |
| D1999 |
|
364 |
322 |
$0.00 |