| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
2,237 |
2,095 |
$863K |
| D1208 |
Topical application of fluoride, excluding varnish |
598 |
577 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
384 |
375 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
730 |
477 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
144 |
$3K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$597.48 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$560.51 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$109.80 |