| Code | Description | Claims | Beneficiaries | Total Paid |
| D1110 |
Prophylaxis - adult |
3,963 |
2,814 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
4,001 |
2,886 |
$69K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,030 |
189 |
$46K |
| D0160 |
|
294 |
252 |
$17K |
| D9420 |
|
250 |
127 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
442 |
284 |
$9K |
| D0330 |
Panoramic radiographic image |
254 |
152 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
207 |
163 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
268 |
$4K |
| D1206 |
Topical application of fluoride varnish |
300 |
257 |
$4K |
| D1120 |
Prophylaxis - child |
113 |
105 |
$3K |
| D4355 |
|
49 |
39 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
41 |
$2K |
| 99199 |
Unlisted special service, procedure or report |
845 |
845 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
45 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
26 |
$414.12 |
| D1330 |
|
21 |
18 |
$0.00 |