| Code | Description | Claims | Beneficiaries | Total Paid |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,738 |
540 |
$238K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,535 |
436 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
472 |
$15K |
| D1120 |
Prophylaxis - child |
459 |
409 |
$14K |
| D1110 |
Prophylaxis - adult |
219 |
199 |
$10K |
| D0272 |
Bitewings - two radiographic images |
462 |
412 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
700 |
631 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
730 |
614 |
$7K |
| D0274 |
Bitewings - four radiographic images |
232 |
213 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
640 |
562 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
160 |
160 |
$4K |
| D1351 |
Sealant - per tooth |
70 |
14 |
$762.48 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
41 |
$406.65 |
| D0603 |
|
726 |
670 |
$0.00 |