| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
231 |
208 |
$34K |
| D1110 |
Prophylaxis - adult |
246 |
246 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
65 |
$6K |
| D0274 |
Bitewings - four radiographic images |
229 |
229 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
236 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
207 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
163 |
163 |
$3K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$3K |
| D1351 |
Sealant - per tooth |
64 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
160 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
17 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
113 |
$808.92 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$473.44 |