| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
4,191 |
3,816 |
$164K |
| D1206 |
Topical application of fluoride varnish |
4,845 |
4,454 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
4,370 |
3,946 |
$93K |
| D0272 |
Bitewings - two radiographic images |
3,169 |
2,903 |
$50K |
| D8660 |
|
799 |
765 |
$35K |
| D1110 |
Prophylaxis - adult |
787 |
730 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
567 |
299 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
956 |
913 |
$29K |
| D0340 |
|
775 |
747 |
$29K |
| D0330 |
Panoramic radiographic image |
1,038 |
984 |
$28K |
| D1351 |
Sealant - per tooth |
1,037 |
277 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
266 |
107 |
$19K |
| D9248 |
|
210 |
187 |
$18K |
| D0274 |
Bitewings - four radiographic images |
676 |
624 |
$14K |
| D0350 |
|
806 |
765 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
310 |
187 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,150 |
1,088 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,097 |
880 |
$12K |
| D9999 |
Unspecified adjunctive procedure, by report |
228 |
228 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
169 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
375 |
357 |
$7K |
| D7240 |
Removal of impacted tooth - completely bony |
45 |
13 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
176 |
$5K |
| D9243 |
|
218 |
57 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
24 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
58 |
58 |
$2K |
| D1999 |
|
217 |
198 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
178 |
144 |
$1K |
| D0601 |
|
992 |
760 |
$1K |
| D0603 |
|
931 |
669 |
$990.95 |
| D9612 |
|
33 |
25 |
$442.00 |
| D0602 |
|
455 |
342 |
$388.25 |
| D9630 |
|
48 |
38 |
$120.00 |