| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
647 |
499 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
56 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
59 |
$935.00 |
| D0274 |
Bitewings - four radiographic images |
119 |
95 |
$768.00 |
| D0120 |
Periodic oral evaluation - established patient |
157 |
140 |
$759.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
124 |
$690.00 |
| D0140 |
Limited oral evaluation - problem focused |
157 |
144 |
$625.00 |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
130 |
$495.00 |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
125 |
$252.00 |