| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
231 |
226 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
237 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
134 |
109 |
$6K |
| D1351 |
Sealant - per tooth |
109 |
42 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
158 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
67 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
120 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
35 |
25 |
$2K |
| D1110 |
Prophylaxis - adult |
54 |
51 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
331 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
78 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
205 |
187 |
$942.40 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$866.70 |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$770.80 |
| D0274 |
Bitewings - four radiographic images |
44 |
43 |
$709.80 |