| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,294 |
2,263 |
$273K |
| D1206 |
Topical application of fluoride varnish |
2,464 |
1,233 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,359 |
483 |
$40K |
| D1120 |
Prophylaxis - child |
1,847 |
952 |
$38K |
| D1354 |
|
1,833 |
413 |
$27K |
| D1351 |
Sealant - per tooth |
2,066 |
371 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,028 |
340 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,934 |
953 |
$18K |
| D0274 |
Bitewings - four radiographic images |
1,105 |
540 |
$10K |
| D0330 |
Panoramic radiographic image |
408 |
202 |
$7K |
| D7111 |
|
262 |
94 |
$7K |
| D0272 |
Bitewings - two radiographic images |
754 |
383 |
$7K |
| D1110 |
Prophylaxis - adult |
446 |
266 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
493 |
233 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
609 |
268 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
42 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
65 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
696 |
315 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
13 |
$2K |
| D2940 |
|
77 |
29 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
143 |
62 |
$1K |
| D0270 |
|
205 |
84 |
$454.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
114 |
51 |
$176.00 |