| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
2,926 |
2,344 |
$304K |
| D1120 |
Prophylaxis - child |
1,595 |
967 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,253 |
571 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
949 |
393 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
2,350 |
1,548 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,934 |
1,223 |
$26K |
| D1206 |
Topical application of fluoride varnish |
699 |
538 |
$20K |
| D1351 |
Sealant - per tooth |
1,201 |
238 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
818 |
517 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
858 |
409 |
$11K |
| D0272 |
Bitewings - two radiographic images |
210 |
140 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
82 |
58 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
200 |
$1K |
| D1110 |
Prophylaxis - adult |
104 |
78 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
27 |
$275.00 |
| D0431 |
|
19 |
14 |
$224.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$32.00 |
| D0603 |
|
256 |
217 |
$0.00 |
| D0602 |
|
169 |
145 |
$0.00 |
| D0024 |
|
136 |
128 |
$0.00 |
| D0601 |
|
20 |
18 |
$0.00 |
| DS001 |
|
59 |
58 |
$0.00 |