| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
538 |
496 |
$48K |
| D1120 |
Prophylaxis - child |
627 |
439 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
543 |
326 |
$25K |
| D1206 |
Topical application of fluoride varnish |
496 |
328 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
309 |
179 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
840 |
652 |
$11K |
| D0274 |
Bitewings - four radiographic images |
427 |
336 |
$8K |
| D1351 |
Sealant - per tooth |
424 |
129 |
$6K |
| D0272 |
Bitewings - two radiographic images |
115 |
81 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
54 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
25 |
$980.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
14 |
$789.00 |
| D0431 |
|
41 |
32 |
$656.00 |
| D1110 |
Prophylaxis - adult |
19 |
15 |
$320.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
16 |
$255.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
17 |
$206.00 |