| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
943 |
943 |
$47K |
| D1206 |
Topical application of fluoride varnish |
900 |
900 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
492 |
$12K |
| D1351 |
Sealant - per tooth |
356 |
100 |
$11K |
| D9920 |
|
123 |
120 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
74 |
$7K |
| D1110 |
Prophylaxis - adult |
139 |
139 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
62 |
$6K |
| D0272 |
Bitewings - two radiographic images |
230 |
230 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
48 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
67 |
$975.52 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$758.66 |