| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
138 |
126 |
$29K |
| D1110 |
Prophylaxis - adult |
458 |
458 |
$14K |
| D1351 |
Sealant - per tooth |
510 |
113 |
$12K |
| D0274 |
Bitewings - four radiographic images |
440 |
440 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
532 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
89 |
$8K |
| D1120 |
Prophylaxis - child |
186 |
186 |
$4K |
| D1206 |
Topical application of fluoride varnish |
221 |
221 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
164 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
269 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
29 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
88 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
134 |
113 |
$829.12 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$573.80 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$435.76 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$218.30 |
| D1999 |
|
80 |
77 |
$0.00 |