| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
4,158 |
3,440 |
$652K |
| D1206 |
Topical application of fluoride varnish |
874 |
460 |
$15K |
| D1120 |
Prophylaxis - child |
634 |
345 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
511 |
283 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
431 |
248 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
976 |
658 |
$6K |
| D0274 |
Bitewings - four radiographic images |
752 |
524 |
$5K |
| D1110 |
Prophylaxis - adult |
1,442 |
1,174 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
509 |
409 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
456 |
379 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
154 |
$625.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
53 |
$600.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
56 |
$450.00 |
| D0220 |
Intraoral - periapical first radiographic image |
311 |
255 |
$430.00 |
| D0330 |
Panoramic radiographic image |
16 |
13 |
$100.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
12 |
$24.00 |