| Code | Description | Claims | Beneficiaries | Total Paid |
| D7140 |
Extraction, erupted tooth or exposed root |
806 |
371 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
549 |
546 |
$30K |
| D1110 |
Prophylaxis - adult |
836 |
827 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
778 |
764 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,102 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
350 |
212 |
$18K |
| D0274 |
Bitewings - four radiographic images |
934 |
927 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
174 |
104 |
$11K |
| D2950 |
|
107 |
95 |
$8K |
| D0330 |
Panoramic radiographic image |
174 |
170 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
15 |
$6K |
| D2335 |
|
54 |
29 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
49 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
218 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
753 |
739 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
410 |
201 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
105 |
$1K |
| D2331 |
|
17 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$642.60 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$489.60 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$193.80 |