| Code | Description | Claims | Beneficiaries | Total Paid |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,230 |
631 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
930 |
567 |
$71K |
| D1110 |
Prophylaxis - adult |
1,766 |
1,702 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,937 |
1,887 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,353 |
1,284 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,029 |
1,008 |
$32K |
| D2330 |
|
508 |
238 |
$31K |
| D1120 |
Prophylaxis - child |
682 |
677 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,895 |
1,824 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,725 |
1,083 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
367 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
573 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
210 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
73 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
24 |
$4K |
| D7250 |
|
24 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
39 |
37 |
$2K |
| D2332 |
|
15 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
16 |
$1K |
| D2940 |
|
17 |
13 |
$480.00 |