| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
380 |
359 |
$171K |
| D1120 |
Prophylaxis - child |
184 |
182 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
20 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
150 |
$0.00 |
| D1351 |
Sealant - per tooth |
75 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
181 |
179 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
19 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
32 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
19 |
17 |
$0.00 |