| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
1,202 |
1,051 |
$159K |
| T1015 |
Clinic visit/encounter, all-inclusive |
18 |
14 |
$1K |
| T1040 |
Medicaid certified community behavioral health clinic services, per diem |
19 |
16 |
$618.56 |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
55 |
$53.55 |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$28.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$26.08 |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$19.94 |
| D0140 |
Limited oral evaluation - problem focused |
105 |
104 |
$19.12 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$0.00 |
| D1120 |
Prophylaxis - child |
221 |
221 |
$0.00 |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
39 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
161 |
161 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
48 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$0.00 |