| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
7,324 |
3,518 |
$700K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,568 |
1,199 |
$534K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,988 |
1,162 |
$436K |
| D0120 |
Periodic oral evaluation - established patient |
17,236 |
17,090 |
$360K |
| D1120 |
Prophylaxis - child |
11,726 |
11,645 |
$350K |
| D1110 |
Prophylaxis - adult |
6,345 |
6,268 |
$286K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,069 |
1,782 |
$179K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,433 |
1,060 |
$156K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
5,830 |
5,479 |
$155K |
| D1206 |
Topical application of fluoride varnish |
9,099 |
8,922 |
$152K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,424 |
9,424 |
$139K |
| D0330 |
Panoramic radiographic image |
2,718 |
2,669 |
$130K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
978 |
523 |
$117K |
| D0272 |
Bitewings - two radiographic images |
5,773 |
5,739 |
$103K |
| D0220 |
Intraoral - periapical first radiographic image |
5,823 |
5,674 |
$87K |
| D0274 |
Bitewings - four radiographic images |
2,736 |
2,689 |
$83K |
| D1351 |
Sealant - per tooth |
2,537 |
682 |
$58K |
| D7240 |
Removal of impacted tooth - completely bony |
242 |
76 |
$52K |
| D0602 |
|
5,532 |
5,511 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,193 |
3,075 |
$46K |
| D0240 |
|
1,311 |
1,311 |
$44K |
| D2934 |
|
315 |
102 |
$37K |
| D3120 |
|
1,213 |
574 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,005 |
980 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
957 |
941 |
$29K |
| D0603 |
|
2,726 |
2,670 |
$25K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
33 |
27 |
$13K |
| D2330 |
|
138 |
65 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
76 |
43 |
$7K |
| D2931 |
|
23 |
12 |
$3K |
| D2140 |
|
58 |
38 |
$3K |
| D2394 |
|
22 |
14 |
$3K |
| D0601 |
|
291 |
291 |
$3K |
| D9310 |
|
37 |
37 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
18 |
$477.18 |