| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
5,252 |
5,248 |
$230K |
| D1351 |
Sealant - per tooth |
9,647 |
2,414 |
$184K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,551 |
1,453 |
$175K |
| D1206 |
Topical application of fluoride varnish |
5,595 |
5,591 |
$172K |
| D0120 |
Periodic oral evaluation - established patient |
5,017 |
5,013 |
$124K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
869 |
612 |
$73K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,409 |
2,372 |
$59K |
| D1353 |
|
6,113 |
1,412 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
356 |
197 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,408 |
2,408 |
$23K |
| D0603 |
|
2,417 |
2,411 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,431 |
1,429 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
3,556 |
3,545 |
$16K |
| D1110 |
Prophylaxis - adult |
388 |
388 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
190 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,029 |
3,020 |
$9K |
| D0601 |
|
989 |
986 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
106 |
67 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
284 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
138 |
$6K |
| D0602 |
|
324 |
324 |
$3K |
| D9920 |
|
41 |
40 |
$1K |
| D7111 |
|
19 |
12 |
$855.00 |