| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
168 |
162 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
192 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
45 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$2K |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$904.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
17 |
$250.00 |