| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
1,053 |
1,050 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,458 |
1,458 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,321 |
1,319 |
$32K |
| D1110 |
Prophylaxis - adult |
548 |
548 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
139 |
$27K |
| D0274 |
Bitewings - four radiographic images |
539 |
539 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
315 |
312 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
69 |
$689.42 |