| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,019 |
825 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
202 |
118 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
233 |
144 |
$2K |
| D0274 |
Bitewings - four radiographic images |
262 |
186 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
307 |
219 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
156 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
146 |
$740.00 |
| D0140 |
Limited oral evaluation - problem focused |
158 |
120 |
$500.00 |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
89 |
$176.00 |
| D0272 |
Bitewings - two radiographic images |
20 |
12 |
$144.00 |