| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,358 |
3,199 |
$531K |
| D1206 |
Topical application of fluoride varnish |
2,197 |
1,108 |
$39K |
| D1120 |
Prophylaxis - child |
1,959 |
992 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
3,604 |
2,369 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
976 |
698 |
$15K |
| D1351 |
Sealant - per tooth |
941 |
180 |
$9K |
| D1110 |
Prophylaxis - adult |
217 |
112 |
$4K |
| D0274 |
Bitewings - four radiographic images |
219 |
128 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
31 |
$1K |