| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,461 |
764 |
$191K |
| D8670 |
Periodic orthodontic treatment visit |
2,513 |
2,399 |
$187K |
| D1110 |
Prophylaxis - adult |
3,027 |
2,917 |
$185K |
| D2750 |
|
368 |
271 |
$166K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,063 |
512 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
3,493 |
3,397 |
$104K |
| D1206 |
Topical application of fluoride varnish |
3,419 |
3,300 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,403 |
1,332 |
$75K |
| D1120 |
Prophylaxis - child |
1,571 |
1,532 |
$69K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
386 |
267 |
$65K |
| D0274 |
Bitewings - four radiographic images |
2,601 |
2,496 |
$59K |
| D0330 |
Panoramic radiographic image |
1,044 |
977 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,590 |
3,352 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
807 |
755 |
$36K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
34 |
34 |
$25K |
| D1351 |
Sealant - per tooth |
718 |
87 |
$23K |
| D8999 |
|
38 |
38 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,813 |
2,674 |
$20K |
| D2950 |
|
210 |
160 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
73 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
350 |
344 |
$8K |
| D1330 |
|
1,288 |
1,243 |
$8K |
| D4355 |
|
57 |
54 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
13 |
$2K |
| D9310 |
|
14 |
14 |
$672.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$210.00 |