| Code | Description | Claims | Beneficiaries | Total Paid |
| D0120 |
Periodic oral evaluation - established patient |
1,197 |
1,079 |
$30K |
| D1110 |
Prophylaxis - adult |
458 |
450 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,009 |
931 |
$19K |
| D0272 |
Bitewings - two radiographic images |
595 |
547 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
159 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
486 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
241 |
226 |
$8K |
| D1120 |
Prophylaxis - child |
174 |
145 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
42 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
51 |
$940.50 |
| D9110 |
|
30 |
30 |
$742.90 |