| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
86 |
83 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
19 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$600.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$588.84 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$588.71 |
| D1110 |
Prophylaxis - adult |
38 |
35 |
$120.00 |