| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,878 |
1,641 |
$378K |
| D0330 |
Panoramic radiographic image |
357 |
357 |
$111.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
269 |
152 |
$65.00 |
| D0140 |
Limited oral evaluation - problem focused |
217 |
216 |
$55.22 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
108 |
$50.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
328 |
$20.00 |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
335 |
$8.00 |
| D0120 |
Periodic oral evaluation - established patient |
49 |
49 |
$0.00 |
| D1330 |
|
343 |
343 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$0.00 |
| D1310 |
|
314 |
314 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
146 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
363 |
363 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
255 |
255 |
$0.00 |
| D1120 |
Prophylaxis - child |
283 |
283 |
$0.00 |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$0.00 |