| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,268 |
2,810 |
$261K |
| D1110 |
Prophylaxis - adult |
6,628 |
5,972 |
$193K |
| D9410 |
|
6,309 |
5,552 |
$185K |
| D1206 |
Topical application of fluoride varnish |
6,320 |
5,738 |
$108K |
| D0190 |
|
4,701 |
3,978 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
1,317 |
1,167 |
$43K |
| D1120 |
Prophylaxis - child |
728 |
721 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,321 |
1,237 |
$26K |
| D0274 |
Bitewings - four radiographic images |
809 |
737 |
$20K |
| D0191 |
|
1,685 |
1,496 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
809 |
603 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
971 |
874 |
$10K |
| D9920 |
|
125 |
114 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
90 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
60 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
18 |
$7K |
| D1351 |
Sealant - per tooth |
197 |
67 |
$6K |
| D0272 |
Bitewings - two radiographic images |
216 |
215 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
31 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
710 |
391 |
$4K |
| D0330 |
Panoramic radiographic image |
50 |
48 |
$3K |
| D9420 |
|
13 |
13 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
46 |
46 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$1K |
| D1354 |
|
92 |
60 |
$67.01 |
| D0603 |
|
2,191 |
1,926 |
$16.97 |
| D0602 |
|
1,232 |
1,071 |
$9.17 |
| D0601 |
|
292 |
279 |
$2.52 |
| D4346 |
|
51 |
47 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |
| D4355 |
|
22 |
22 |
$0.00 |
| D9996 |
|
1,211 |
1,100 |
$0.00 |
| D0350 |
|
2,102 |
1,768 |
$0.00 |
| D9932 |
|
1,413 |
856 |
$0.00 |
| D9933 |
|
492 |
289 |
$0.00 |