| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
708 |
667 |
$79K |
| D1110 |
Prophylaxis - adult |
487 |
485 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
530 |
$6K |
| D1206 |
Topical application of fluoride varnish |
302 |
300 |
$1K |
| D1120 |
Prophylaxis - child |
171 |
171 |
$1K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$756.17 |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$293.45 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
35 |
$60.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$58.70 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$48.00 |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
87 |
$31.35 |
| D0603 |
|
12 |
12 |
$0.00 |
| D1351 |
Sealant - per tooth |
170 |
27 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$0.00 |
| D9110 |
|
20 |
20 |
$0.00 |