| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
163 |
$27K |
| D1110 |
Prophylaxis - adult |
342 |
339 |
$16K |
| D1120 |
Prophylaxis - child |
321 |
320 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
423 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
275 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
153 |
$9K |
| D1206 |
Topical application of fluoride varnish |
373 |
371 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
41 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
44 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
402 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
143 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
13 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
457 |
263 |
$4K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$3K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$276.00 |