| Code | Description | Claims | Beneficiaries | Total Paid |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,834 |
382 |
$195K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,280 |
589 |
$136K |
| D2394 |
|
687 |
409 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,243 |
1,129 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
344 |
$53K |
| D7311 |
|
319 |
193 |
$52K |
| D2335 |
|
326 |
130 |
$45K |
| D0330 |
Panoramic radiographic image |
1,159 |
1,064 |
$39K |
| D2332 |
|
224 |
112 |
$26K |
| D7250 |
|
191 |
41 |
$23K |
| D4341 |
|
472 |
118 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
587 |
535 |
$19K |
| D0274 |
Bitewings - four radiographic images |
940 |
871 |
$14K |
| D3310 |
|
26 |
12 |
$12K |
| D1110 |
Prophylaxis - adult |
236 |
234 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
509 |
479 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,653 |
936 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,059 |
973 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
105 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
94 |
$3K |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$322.54 |