| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
4,475 |
4,217 |
$687K |
| T1015 |
Clinic visit/encounter, all-inclusive |
150 |
131 |
$21K |
| D1120 |
Prophylaxis - child |
835 |
833 |
$147.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,122 |
1,119 |
$115.40 |
| D1206 |
Topical application of fluoride varnish |
1,251 |
1,248 |
$73.50 |
| D1110 |
Prophylaxis - adult |
193 |
192 |
$54.88 |
| D1330 |
|
427 |
427 |
$12.25 |
| D0274 |
Bitewings - four radiographic images |
87 |
86 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
357 |
357 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
247 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$0.00 |
| D0603 |
|
2,220 |
2,203 |
$0.00 |
| D1310 |
|
721 |
721 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
279 |
279 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
202 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$0.00 |