| Code | Description | Claims | Beneficiaries | Total Paid |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
108 |
56 |
$13K |
| D1120 |
Prophylaxis - child |
289 |
289 |
$10K |
| D1206 |
Topical application of fluoride varnish |
325 |
325 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
251 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
48 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
141 |
135 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
36 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
34 |
$4K |
| D1351 |
Sealant - per tooth |
86 |
27 |
$3K |
| D9248 |
|
29 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
45 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
98 |
$1K |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$907.20 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$780.69 |