| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
11,398 |
9,335 |
$2.25M |
| D0120 |
Periodic oral evaluation - established patient |
4,087 |
4,062 |
$112K |
| D1120 |
Prophylaxis - child |
3,001 |
2,984 |
$72K |
| D1206 |
Topical application of fluoride varnish |
3,156 |
3,131 |
$65K |
| D0330 |
Panoramic radiographic image |
1,549 |
1,536 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
701 |
507 |
$49K |
| D1110 |
Prophylaxis - adult |
677 |
672 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
3,164 |
2,542 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
586 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,898 |
1,880 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
243 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
672 |
653 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,338 |
1,333 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
854 |
853 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,956 |
1,837 |
$13K |
| D4341 |
|
269 |
173 |
$11K |
| D1351 |
Sealant - per tooth |
355 |
143 |
$6K |
| D0240 |
|
363 |
233 |
$3K |
| D9992 |
|
65 |
59 |
$915.00 |
| D9995 |
|
58 |
50 |
$850.00 |
| D0270 |
|
72 |
68 |
$658.08 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$657.46 |
| D0460 |
|
30 |
28 |
$29.10 |
| D0190 |
|
58 |
50 |
$0.00 |