| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
671 |
591 |
$107K |
| D1120 |
Prophylaxis - child |
568 |
485 |
$24K |
| D1206 |
Topical application of fluoride varnish |
680 |
586 |
$24K |
| D1351 |
Sealant - per tooth |
339 |
94 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
327 |
286 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
79 |
$5K |
| D0274 |
Bitewings - four radiographic images |
252 |
231 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
47 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
202 |
$4K |
| D1110 |
Prophylaxis - adult |
94 |
86 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
213 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
206 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
67 |
$755.00 |
| D0272 |
Bitewings - two radiographic images |
44 |
38 |
$734.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$720.00 |