| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
870 |
829 |
$177K |
| D9999 |
Unspecified adjunctive procedure, by report |
29 |
29 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
57 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
251 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
51 |
$731.07 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$342.00 |
| D1110 |
Prophylaxis - adult |
209 |
209 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
158 |
158 |
$0.00 |
| D1120 |
Prophylaxis - child |
158 |
158 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
388 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
566 |
566 |
$0.00 |
| D1351 |
Sealant - per tooth |
42 |
12 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
148 |
148 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$0.00 |