| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
16,198 |
15,930 |
$340K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,387 |
2,001 |
$335K |
| D1120 |
Prophylaxis - child |
11,077 |
10,926 |
$331K |
| D1110 |
Prophylaxis - adult |
6,411 |
6,280 |
$290K |
| D1206 |
Topical application of fluoride varnish |
12,854 |
12,585 |
$208K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,366 |
898 |
$178K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,158 |
435 |
$138K |
| D0274 |
Bitewings - four radiographic images |
4,266 |
4,180 |
$130K |
| D0220 |
Intraoral - periapical first radiographic image |
8,290 |
7,941 |
$126K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
4,375 |
3,841 |
$116K |
| D0330 |
Panoramic radiographic image |
2,308 |
2,205 |
$112K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,091 |
362 |
$98K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,393 |
880 |
$93K |
| D0272 |
Bitewings - two radiographic images |
4,755 |
4,698 |
$86K |
| D0140 |
Limited oral evaluation - problem focused |
1,938 |
1,905 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,948 |
3,948 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,691 |
1,652 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,494 |
5,333 |
$50K |
| D0602 |
|
5,106 |
5,033 |
$46K |
| D1351 |
Sealant - per tooth |
1,560 |
476 |
$35K |
| D0603 |
|
3,483 |
3,420 |
$32K |
| D0240 |
|
814 |
809 |
$26K |
| D7111 |
|
266 |
194 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
225 |
172 |
$12K |
| D7240 |
Removal of impacted tooth - completely bony |
37 |
12 |
$8K |
| D3120 |
|
131 |
94 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
39 |
39 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
16 |
$716.81 |
| D0601 |
|
45 |
45 |
$411.75 |