| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
532 |
451 |
$100K |
| D0274 |
Bitewings - four radiographic images |
312 |
202 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
156 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
167 |
$1K |
| D1206 |
Topical application of fluoride varnish |
59 |
32 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
49 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
57 |
$800.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
29 |
$653.00 |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
71 |
$290.00 |
| D0140 |
Limited oral evaluation - problem focused |
48 |
37 |
$110.00 |
| D0603 |
|
62 |
61 |
$0.00 |
| D0602 |
|
88 |
86 |
$0.00 |
| D0601 |
|
55 |
53 |
$0.00 |