| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
723 |
701 |
$307K |
| D1351 |
Sealant - per tooth |
102 |
34 |
$136.00 |
| D1206 |
Topical application of fluoride varnish |
340 |
339 |
$84.00 |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$77.00 |
| D1120 |
Prophylaxis - child |
311 |
310 |
$73.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
191 |
$63.00 |
| D0272 |
Bitewings - two radiographic images |
136 |
135 |
$26.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
32 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$0.00 |
| D1330 |
|
75 |
75 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
109 |
$0.00 |
| D1310 |
|
61 |
61 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
146 |
$0.00 |