| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
5,764 |
4,674 |
$242K |
| D1999 |
|
226 |
193 |
$0.00 |
| D1110 |
Prophylaxis - adult |
409 |
385 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,466 |
1,309 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,560 |
1,425 |
$0.00 |
| D0330 |
Panoramic radiographic image |
223 |
189 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
492 |
439 |
$0.00 |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
123 |
113 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
186 |
$0.00 |
| 99392 |
Periodic comprehensive preventive medicine reevaluation, established patient, early childhood (1-4 years) |
15 |
13 |
$0.00 |
| 90461 |
|
31 |
29 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,581 |
983 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
796 |
727 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
2,169 |
1,992 |
$0.00 |
| D0603 |
|
382 |
351 |
$0.00 |
| D1330 |
|
1,077 |
957 |
$0.00 |
| D1351 |
Sealant - per tooth |
382 |
141 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,613 |
1,486 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
162 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
390 |
275 |
$0.00 |
| D0602 |
|
134 |
131 |
$0.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
146 |
124 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$0.00 |
| 90686 |
|
50 |
48 |
$0.00 |