| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,703 |
1,603 |
$346K |
| D1110 |
Prophylaxis - adult |
1,447 |
1,444 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,229 |
1,228 |
$26K |
| D0274 |
Bitewings - four radiographic images |
814 |
810 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
511 |
511 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
57 |
$6K |
| D1120 |
Prophylaxis - child |
481 |
479 |
$4K |
| D0330 |
Panoramic radiographic image |
324 |
322 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
432 |
430 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$803.10 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
440 |
436 |
$738.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
142 |
$487.75 |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
292 |
$155.80 |
| D1206 |
Topical application of fluoride varnish |
487 |
485 |
$54.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| D1310 |
|
59 |
59 |
$0.00 |