| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
144 |
130 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
99 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
41 |
$3K |
| D0272 |
Bitewings - two radiographic images |
86 |
79 |
$2K |
| D1206 |
Topical application of fluoride varnish |
90 |
80 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
67 |
$990.73 |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$712.53 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
47 |
$549.12 |