| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
262 |
259 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
323 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
304 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
871 |
866 |
$11K |
| D0350 |
|
527 |
408 |
$11K |
| D0274 |
Bitewings - four radiographic images |
358 |
354 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
40 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,231 |
636 |
$5K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$2K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$2K |