| Code | Description | Claims | Beneficiaries | Total Paid |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
370 |
231 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
367 |
200 |
$21K |
| D1110 |
Prophylaxis - adult |
459 |
445 |
$13K |
| D2140 |
|
192 |
138 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
223 |
$10K |
| D0274 |
Bitewings - four radiographic images |
341 |
331 |
$10K |
| D1120 |
Prophylaxis - child |
245 |
235 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
429 |
416 |
$9K |
| D2332 |
|
90 |
52 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
167 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
232 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
182 |
$5K |
| D2160 |
|
53 |
41 |
$4K |
| D2330 |
|
22 |
17 |
$982.00 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
84 |
$636.50 |