| Code | Description | Claims | Beneficiaries | Total Paid |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
433 |
220 |
$58K |
| D1110 |
Prophylaxis - adult |
1,113 |
1,087 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
332 |
325 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
582 |
571 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
840 |
818 |
$12K |
| D0274 |
Bitewings - four radiographic images |
355 |
350 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
312 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
172 |
71 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
207 |
202 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
690 |
488 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
59 |
$4K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
31 |
$3K |
| D1206 |
Topical application of fluoride varnish |
111 |
108 |
$3K |
| D2332 |
|
16 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$714.00 |