| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
832 |
774 |
$143K |
| D1110 |
Prophylaxis - adult |
223 |
222 |
$46.80 |
| D1206 |
Topical application of fluoride varnish |
332 |
331 |
$41.76 |
| D0120 |
Periodic oral evaluation - established patient |
236 |
235 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
28 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$0.00 |
| D1120 |
Prophylaxis - child |
241 |
241 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
102 |
$0.00 |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$0.00 |