| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
1,424 |
1,372 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,943 |
1,862 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
660 |
643 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
764 |
746 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
620 |
$14K |
| D1110 |
Prophylaxis - adult |
359 |
353 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
113 |
$10K |
| D0274 |
Bitewings - four radiographic images |
583 |
559 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
478 |
432 |
$8K |
| D1351 |
Sealant - per tooth |
103 |
65 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
295 |
293 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
25 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
152 |
$703.36 |