| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
14,105 |
12,569 |
$2.29M |
| D1206 |
Topical application of fluoride varnish |
6,563 |
3,757 |
$132K |
| D1120 |
Prophylaxis - child |
5,128 |
3,125 |
$119K |
| D1110 |
Prophylaxis - adult |
4,875 |
3,993 |
$47K |
| D1351 |
Sealant - per tooth |
4,085 |
777 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,717 |
1,303 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
2,213 |
1,732 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
3,008 |
2,532 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
428 |
239 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,393 |
887 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
409 |
326 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
274 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
341 |
213 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
2,712 |
2,242 |
$4K |
| D9992 |
|
380 |
349 |
$740.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
44 |
$120.00 |
| D9995 |
|
22 |
22 |
$0.00 |