| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
3,402 |
2,914 |
$517K |
| D1206 |
Topical application of fluoride varnish |
410 |
408 |
$38.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$0.00 |
| D1330 |
|
522 |
518 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
423 |
423 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
21 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$0.00 |
| D1120 |
Prophylaxis - child |
161 |
161 |
$0.00 |
| D1110 |
Prophylaxis - adult |
277 |
277 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
70 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$0.00 |