| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 00003 |
Internal/system code - not a standard HCPCS code |
10,740 |
10,171 |
$2.48M |
| T1015 |
Clinic visit/encounter, all-inclusive |
8,869 |
5,405 |
$1.06M |
| D1206 |
Topical application of fluoride varnish |
2,483 |
2,448 |
$11K |
| D1120 |
Prophylaxis - child |
466 |
466 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
1,780 |
1,751 |
$3K |
| D1310 |
|
541 |
531 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
107 |
$624.00 |
| D0603 |
|
299 |
293 |
$465.00 |
| D1351 |
Sealant - per tooth |
22 |
14 |
$364.50 |
| D0220 |
Intraoral - periapical first radiographic image |
1,177 |
939 |
$251.00 |
| D0274 |
Bitewings - four radiographic images |
369 |
361 |
$203.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
533 |
424 |
$37.50 |
| D0602 |
|
48 |
48 |
$30.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$15.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
13 |
$0.00 |
| D0191 |
|
332 |
324 |
$0.00 |