| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
431 |
333 |
$56K |
| D1206 |
Topical application of fluoride varnish |
596 |
380 |
$21K |
| D1120 |
Prophylaxis - child |
469 |
305 |
$20K |
| D1351 |
Sealant - per tooth |
350 |
75 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
54 |
$7K |
| D1110 |
Prophylaxis - adult |
163 |
93 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
215 |
$5K |
| D0274 |
Bitewings - four radiographic images |
281 |
182 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
49 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
130 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
246 |
160 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
232 |
153 |
$1K |
| D0272 |
Bitewings - two radiographic images |
73 |
48 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$55.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
12 |
$0.00 |