| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,019 |
956 |
$82K |
| D1120 |
Prophylaxis - child |
1,266 |
1,111 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,304 |
1,121 |
$24K |
| D1351 |
Sealant - per tooth |
1,187 |
332 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
566 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
105 |
$8K |
| D0274 |
Bitewings - four radiographic images |
176 |
168 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
49 |
$2K |
| D1110 |
Prophylaxis - adult |
146 |
125 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |
| D0431 |
|
24 |
21 |
$208.00 |
| D0602 |
|
22 |
22 |
$0.00 |