| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
609 |
519 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,021 |
857 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
249 |
212 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
210 |
80 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
671 |
557 |
$13K |
| D0272 |
Bitewings - two radiographic images |
442 |
367 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
488 |
390 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
163 |
127 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
50 |
$1K |
| D1120 |
Prophylaxis - child |
21 |
12 |
$758.10 |