| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
9,449 |
4,970 |
$952K |
| D1206 |
Topical application of fluoride varnish |
3,117 |
2,489 |
$30K |
| D1120 |
Prophylaxis - child |
1,914 |
1,911 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,502 |
1,500 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,928 |
1,922 |
$18K |
| D1351 |
Sealant - per tooth |
979 |
318 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,063 |
1,062 |
$9K |
| D1110 |
Prophylaxis - adult |
539 |
539 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,427 |
1,392 |
$4K |
| D1999 |
|
314 |
289 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
514 |
499 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
82 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
343 |
343 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
199 |
197 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
298 |
243 |
$607.70 |
| D1354 |
|
87 |
30 |
$469.20 |
| D7140 |
Extraction, erupted tooth or exposed root |
207 |
116 |
$154.08 |
| D0999 |
Unspecified diagnostic procedure, by report |
190 |
153 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
26 |
$0.00 |
| D0330 |
Panoramic radiographic image |
144 |
144 |
$0.00 |