| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
2,577 |
2,139 |
$586K |
| D0603 |
|
22 |
22 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
1,003 |
920 |
$0.00 |
| D1351 |
Sealant - per tooth |
517 |
148 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
392 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
39 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
31 |
31 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
70 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$0.00 |
| D1330 |
|
18 |
18 |
$0.00 |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$0.00 |
| D1120 |
Prophylaxis - child |
182 |
157 |
$0.00 |
| D0330 |
Panoramic radiographic image |
202 |
159 |
$0.00 |
| D0191 |
|
661 |
635 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
122 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
120 |
87 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
18 |
$0.00 |