| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
375 |
326 |
$101K |
| D1110 |
Prophylaxis - adult |
339 |
339 |
$13K |
| D0274 |
Bitewings - four radiographic images |
467 |
466 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
423 |
421 |
$9K |
| D1120 |
Prophylaxis - child |
210 |
208 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
279 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
218 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
594 |
575 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
652 |
442 |
$4K |
| D1351 |
Sealant - per tooth |
103 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
49 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$234.00 |
| D0140 |
Limited oral evaluation - problem focused |
68 |
67 |
$0.00 |
| D0270 |
|
12 |
12 |
$0.00 |
| D1999 |
|
49 |
49 |
$0.00 |