| Code | Description | Claims | Beneficiaries | Total Paid |
| D0999 |
Unspecified diagnostic procedure, by report |
1,144 |
825 |
$27K |
| D1206 |
Topical application of fluoride varnish |
467 |
419 |
$24K |
| D1120 |
Prophylaxis - child |
409 |
368 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
120 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
190 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
43 |
39 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
320 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
36 |
30 |
$436.36 |
| D0330 |
Panoramic radiographic image |
21 |
17 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
16 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
30 |
$0.00 |