| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
515 |
449 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
434 |
428 |
$7K |
| D1120 |
Prophylaxis - child |
308 |
289 |
$6K |
| D1110 |
Prophylaxis - adult |
217 |
211 |
$5K |
| D1206 |
Topical application of fluoride varnish |
346 |
325 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
62 |
$1K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$448.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
68 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$64.00 |