| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,040 |
960 |
$116K |
| D1206 |
Topical application of fluoride varnish |
2,128 |
1,738 |
$63K |
| D1120 |
Prophylaxis - child |
1,248 |
1,049 |
$41K |
| D1110 |
Prophylaxis - adult |
901 |
769 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,098 |
952 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,222 |
1,061 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
440 |
250 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
174 |
$13K |
| D1351 |
Sealant - per tooth |
602 |
128 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
403 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
117 |
$676.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$630.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
16 |
$408.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
25 |
$135.00 |
| D0601 |
|
45 |
45 |
$0.00 |
| D0603 |
|
144 |
142 |
$0.00 |
| D0602 |
|
64 |
63 |
$0.00 |