| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
10,280 |
10,268 |
$394K |
| D0120 |
Periodic oral evaluation - established patient |
12,838 |
12,820 |
$327K |
| D0274 |
Bitewings - four radiographic images |
10,977 |
10,969 |
$274K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,624 |
2,322 |
$222K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,708 |
1,236 |
$170K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,485 |
12,470 |
$159K |
| D1351 |
Sealant - per tooth |
4,098 |
1,327 |
$151K |
| D0220 |
Intraoral - periapical first radiographic image |
12,308 |
12,260 |
$146K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,978 |
1,848 |
$139K |
| D1110 |
Prophylaxis - adult |
2,711 |
2,707 |
$135K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,786 |
1,787 |
$125K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
420 |
325 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,175 |
5,149 |
$28K |
| D1206 |
Topical application of fluoride varnish |
501 |
500 |
$12K |
| D9310 |
|
72 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
155 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D9990 |
|
55 |
52 |
$771.62 |
| D2330 |
|
14 |
13 |
$751.80 |
| D1999 |
|
80 |
79 |
$0.00 |