| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,646 |
1,357 |
$210K |
| D0210 |
Intraoral - complete series of radiographic images |
99 |
99 |
$108.00 |
| D1110 |
Prophylaxis - adult |
116 |
116 |
$81.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$24.00 |
| D0120 |
Periodic oral evaluation - established patient |
246 |
246 |
$24.00 |
| D1330 |
|
521 |
511 |
$20.00 |
| D1310 |
|
338 |
336 |
$10.00 |
| D0274 |
Bitewings - four radiographic images |
144 |
144 |
$0.00 |
| D1120 |
Prophylaxis - child |
52 |
52 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
253 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
79 |
$0.00 |
| D9110 |
|
35 |
34 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
57 |
54 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
111 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
199 |
198 |
$0.00 |
| D0603 |
|
185 |
185 |
$0.00 |
| D0602 |
|
42 |
42 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
28 |
$0.00 |
| D5899 |
|
78 |
60 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |
| D0601 |
|
81 |
81 |
$0.00 |