| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
462 |
428 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,156 |
836 |
$28K |
| D1120 |
Prophylaxis - child |
931 |
685 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
466 |
283 |
$16K |
| D1351 |
Sealant - per tooth |
935 |
227 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
353 |
220 |
$10K |
| D0330 |
Panoramic radiographic image |
220 |
217 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
696 |
$8K |
| D0274 |
Bitewings - four radiographic images |
265 |
261 |
$6K |
| D0272 |
Bitewings - two radiographic images |
308 |
298 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
208 |
$4K |
| D1354 |
|
386 |
125 |
$4K |
| D1110 |
Prophylaxis - adult |
173 |
137 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
69 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
102 |
$758.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$252.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$31.00 |
| D1330 |
|
397 |
368 |
$0.00 |
| D1310 |
|
57 |
53 |
$0.00 |
| D0602 |
|
230 |
217 |
$0.00 |
| D3120 |
|
26 |
22 |
$0.00 |
| D0603 |
|
105 |
99 |
$0.00 |