| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
148 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
727 |
467 |
$19K |
| D1110 |
Prophylaxis - adult |
603 |
439 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
490 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
93 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,209 |
815 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
245 |
152 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,021 |
396 |
$7K |
| D1206 |
Topical application of fluoride varnish |
542 |
374 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
227 |
143 |
$5K |
| D1120 |
Prophylaxis - child |
161 |
122 |
$3K |
| D0274 |
Bitewings - four radiographic images |
158 |
102 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
51 |
37 |
$1K |
| D4355 |
|
27 |
13 |
$835.28 |