| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
26,545 |
21,296 |
$4.20M |
| D1120 |
Prophylaxis - child |
8,029 |
5,936 |
$256K |
| D1206 |
Topical application of fluoride varnish |
9,599 |
6,901 |
$246K |
| D1110 |
Prophylaxis - adult |
13,925 |
12,170 |
$94K |
| D1351 |
Sealant - per tooth |
4,694 |
1,088 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
5,885 |
4,775 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
966 |
573 |
$43K |
| D0274 |
Bitewings - four radiographic images |
4,736 |
3,806 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,169 |
686 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,346 |
1,098 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
884 |
599 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
3,819 |
3,272 |
$20K |
| D2140 |
|
434 |
254 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
371 |
235 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
4,119 |
3,524 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
280 |
206 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
734 |
648 |
$6K |
| D0272 |
Bitewings - two radiographic images |
307 |
238 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
157 |
128 |
$4K |
| D2160 |
|
200 |
147 |
$4K |
| D2332 |
|
60 |
51 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
756 |
444 |
$960.00 |
| D2335 |
|
72 |
58 |
$800.00 |
| D2330 |
|
36 |
26 |
$600.00 |
| D9992 |
|
80 |
77 |
$60.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
322 |
256 |
$0.00 |