| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,598 |
3,341 |
$443K |
| D1206 |
Topical application of fluoride varnish |
3,769 |
1,828 |
$70K |
| D1120 |
Prophylaxis - child |
2,889 |
1,452 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,419 |
579 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,431 |
540 |
$35K |
| D1351 |
Sealant - per tooth |
2,204 |
382 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
2,382 |
1,138 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,219 |
627 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,299 |
667 |
$16K |
| D1354 |
|
1,037 |
251 |
$13K |
| D0330 |
Panoramic radiographic image |
536 |
304 |
$13K |
| D7111 |
|
486 |
173 |
$11K |
| D1110 |
Prophylaxis - adult |
657 |
400 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,076 |
515 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
743 |
370 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
65 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
598 |
334 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
43 |
$184.00 |