| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,459 |
1,194 |
$207K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
83 |
$3K |
| D1206 |
Topical application of fluoride varnish |
196 |
95 |
$3K |
| D1120 |
Prophylaxis - child |
93 |
47 |
$2K |
| D1110 |
Prophylaxis - adult |
217 |
168 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
147 |
$1K |
| D0274 |
Bitewings - four radiographic images |
143 |
98 |
$840.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
12 |
$660.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
40 |
$630.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
18 |
$270.00 |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
94 |
$156.00 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
33 |
$50.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |