| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
2,108 |
2,107 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
3,784 |
3,782 |
$89K |
| D0220 |
Intraoral - periapical first radiographic image |
4,479 |
4,433 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,706 |
1,706 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,805 |
3,801 |
$29K |
| D1120 |
Prophylaxis - child |
484 |
484 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
823 |
823 |
$10K |
| D1351 |
Sealant - per tooth |
26 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
93 |
$3K |
| D0272 |
Bitewings - two radiographic images |
181 |
181 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
24 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$338.75 |