| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,161 |
1,115 |
$37K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
261 |
166 |
$16K |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
451 |
312 |
$13K |
| D1120 |
Prophylaxis - child |
218 |
212 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
379 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
101 |
$5K |
| D0274 |
Bitewings - four radiographic images |
553 |
536 |
$5K |
| T1015 |
Clinic visit/encounter, all-inclusive |
89 |
59 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
72 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
41 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
50 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
513 |
503 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
38 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
397 |
383 |
$685.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
86 |
$104.00 |
| D1206 |
Topical application of fluoride varnish |
194 |
189 |
$75.32 |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
230 |
$15.00 |
| T1013 |
Sign language or oral interpretive services, per 15 minutes |
25 |
12 |
$0.00 |