| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
785 |
730 |
$185K |
| D1330 |
|
160 |
160 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
162 |
162 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
142 |
142 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
70 |
69 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
88 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$0.00 |
| D1351 |
Sealant - per tooth |
62 |
14 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$0.00 |
| D1110 |
Prophylaxis - adult |
209 |
209 |
$0.00 |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
28 |
$0.00 |
| D1120 |
Prophylaxis - child |
55 |
55 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$0.00 |