| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
644 |
298 |
$0.00 |
| D0330 |
Panoramic radiographic image |
120 |
63 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
150 |
79 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
124 |
$0.00 |
| D4341 |
|
108 |
47 |
$0.00 |
| D1120 |
Prophylaxis - child |
98 |
51 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
21 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
188 |
98 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
54 |
28 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
514 |
113 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
108 |
57 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
30 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
66 |
$0.00 |