| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
7,888 |
7,876 |
$247K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,217 |
5,210 |
$181K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,010 |
7,997 |
$145K |
| D0274 |
Bitewings - four radiographic images |
4,274 |
4,270 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
3,551 |
3,546 |
$80K |
| D0272 |
Bitewings - two radiographic images |
3,039 |
3,035 |
$62K |
| D1110 |
Prophylaxis - adult |
810 |
809 |
$37K |
| D9110 |
|
469 |
458 |
$26K |
| D1351 |
Sealant - per tooth |
498 |
144 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
175 |
132 |
$10K |
| D0330 |
Panoramic radiographic image |
160 |
160 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
193 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
491 |
480 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
56 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$1K |