| Code | Description | Claims | Beneficiaries | Total Paid |
| T1015 |
Clinic visit/encounter, all-inclusive |
2,094 |
1,734 |
$588K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
550 |
$24K |
| D0330 |
Panoramic radiographic image |
450 |
435 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
156 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
145 |
$14K |
| D1206 |
Topical application of fluoride varnish |
570 |
552 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
762 |
731 |
$7K |
| D1120 |
Prophylaxis - child |
211 |
205 |
$5K |
| D4341 |
|
126 |
92 |
$5K |
| D1110 |
Prophylaxis - adult |
102 |
94 |
$5K |
| D0274 |
Bitewings - four radiographic images |
335 |
324 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
101 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,254 |
650 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
45 |
41 |
$1K |
| D0272 |
Bitewings - two radiographic images |
93 |
89 |
$895.37 |
| D0603 |
|
105 |
105 |
$0.00 |