| Code | Description | Claims | Beneficiaries | Total Paid |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
99 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
73 |
$984.89 |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$958.45 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$845.37 |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$302.25 |