| Code | Description | Claims | Beneficiaries | Total Paid |
| D1120 |
Prophylaxis - child |
621 |
505 |
$9K |
| D0330 |
Panoramic radiographic image |
317 |
249 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
805 |
647 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
411 |
329 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
497 |
417 |
$4K |
| D0274 |
Bitewings - four radiographic images |
175 |
132 |
$3K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
16 |
14 |
$738.36 |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
32 |
$494.05 |
| D0140 |
Limited oral evaluation - problem focused |
83 |
77 |
$346.48 |
| D1110 |
Prophylaxis - adult |
179 |
175 |
$321.13 |
| D0272 |
Bitewings - two radiographic images |
71 |
69 |
$99.24 |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
99 |
$38.65 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
47 |
$17.23 |
| D9999 |
Unspecified adjunctive procedure, by report |
42 |
33 |
$0.00 |
| T1015 |
Clinic visit/encounter, all-inclusive |
50 |
30 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
13 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$0.00 |