| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
4,230 |
3,770 |
$308K |
| D1110 |
Prophylaxis - adult |
1,875 |
1,343 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
2,416 |
1,747 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
258 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
230 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,982 |
1,400 |
$20K |
| D1120 |
Prophylaxis - child |
1,370 |
956 |
$18K |
| D0274 |
Bitewings - four radiographic images |
1,666 |
1,195 |
$17K |
| D0330 |
Panoramic radiographic image |
216 |
198 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,305 |
896 |
$15K |
| D2331 |
|
23 |
14 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
480 |
309 |
$1K |
| D0272 |
Bitewings - two radiographic images |
108 |
70 |
$652.65 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
25 |
$406.44 |
| D0603 |
|
14 |
14 |
$0.00 |