| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
1,362 |
1,362 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
219 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
725 |
725 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
299 |
212 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
591 |
590 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
36 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
53 |
$4K |