| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
211 |
208 |
$6K |
| D0330 |
Panoramic radiographic image |
143 |
141 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
48 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
267 |
264 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
147 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
37 |
$3K |
| D0274 |
Bitewings - four radiographic images |
116 |
115 |
$2K |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$946.00 |
| D1120 |
Prophylaxis - child |
36 |
36 |
$730.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$716.94 |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
144 |
$698.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
24 |
$564.50 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$184.00 |