| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,132 |
1,069 |
$217K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
18 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$2K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$780.00 |
| D0274 |
Bitewings - four radiographic images |
221 |
221 |
$408.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
297 |
296 |
$390.00 |
| D0120 |
Periodic oral evaluation - established patient |
246 |
245 |
$389.88 |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
154 |
$204.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
88 |
71 |
$0.00 |
| D2140 |
|
91 |
69 |
$0.00 |
| D0330 |
Panoramic radiographic image |
206 |
206 |
$0.00 |
| D1110 |
Prophylaxis - adult |
119 |
119 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
163 |
93 |
$0.00 |
| D2331 |
|
17 |
12 |
$0.00 |