| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,937 |
3,441 |
$550K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,137 |
643 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,291 |
660 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
936 |
$8K |
| D0274 |
Bitewings - four radiographic images |
1,041 |
736 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
502 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
375 |
200 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
576 |
485 |
$3K |
| D1351 |
Sealant - per tooth |
264 |
48 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
619 |
477 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
79 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
771 |
459 |
$1K |
| D1120 |
Prophylaxis - child |
43 |
29 |
$1K |
| D1206 |
Topical application of fluoride varnish |
51 |
24 |
$796.49 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$602.91 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$336.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
18 |
$270.00 |