| Code | Description | Claims | Beneficiaries | Total Paid |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
256 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
102 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
29 |
$3K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
504 |
253 |
$2K |
| D0274 |
Bitewings - four radiographic images |
172 |
170 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
97 |
$2K |
| D0330 |
Panoramic radiographic image |
43 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
271 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$720.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$361.28 |