| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
23,378 |
20,798 |
$3.74M |
| D1206 |
Topical application of fluoride varnish |
9,200 |
5,924 |
$185K |
| D1120 |
Prophylaxis - child |
6,536 |
4,391 |
$143K |
| D1110 |
Prophylaxis - adult |
17,353 |
15,332 |
$85K |
| D1351 |
Sealant - per tooth |
5,030 |
865 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,920 |
1,675 |
$4K |
| D0274 |
Bitewings - four radiographic images |
1,246 |
1,085 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
543 |
447 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
898 |
809 |
$945.00 |
| D0210 |
Intraoral - complete series of radiographic images |
299 |
269 |
$740.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,159 |
1,062 |
$452.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
42 |
$136.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$34.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
31 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
39 |
24 |
$0.00 |