| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
518 |
481 |
$76K |
| D1206 |
Topical application of fluoride varnish |
1,025 |
795 |
$29K |
| D0274 |
Bitewings - four radiographic images |
907 |
753 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,065 |
865 |
$15K |
| D1120 |
Prophylaxis - child |
202 |
144 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
65 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
54 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
209 |
176 |
$4K |
| D1110 |
Prophylaxis - adult |
150 |
108 |
$3K |
| D1351 |
Sealant - per tooth |
71 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
42 |
$398.00 |
| D0603 |
|
29 |
29 |
$0.00 |
| D0601 |
|
68 |
67 |
$0.00 |
| D0602 |
|
29 |
29 |
$0.00 |