| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
12,208 |
11,987 |
$807K |
| D1110 |
Prophylaxis - adult |
6,217 |
6,124 |
$402K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,138 |
2,683 |
$253K |
| D0330 |
Panoramic radiographic image |
1,685 |
1,641 |
$106K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
3,001 |
2,828 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
18,215 |
17,895 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
17,066 |
16,776 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
884 |
880 |
$52K |
| D1351 |
Sealant - per tooth |
7,102 |
2,049 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,417 |
1,023 |
$49K |
| D1330 |
|
18,538 |
18,216 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
748 |
738 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,137 |
16,410 |
$36K |
| D0272 |
Bitewings - two radiographic images |
10,412 |
10,229 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
17,695 |
17,313 |
$30K |
| D9920 |
|
4,955 |
4,837 |
$26K |
| D7111 |
|
395 |
270 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
930 |
892 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
247 |
156 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
64 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
63 |
$8K |
| D1999 |
|
383 |
375 |
$6K |
| D0274 |
Bitewings - four radiographic images |
4,399 |
4,321 |
$2K |
| D9996 |
|
65 |
43 |
$600.96 |
| D9995 |
|
66 |
44 |
$432.48 |
| D3120 |
|
179 |
150 |
$71.96 |
| D9986 |
|
293 |
292 |
$0.00 |