| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
294 |
283 |
$133K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$0.00 |
| D1120 |
Prophylaxis - child |
77 |
77 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
34 |
34 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$0.00 |
| D1310 |
|
51 |
51 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$0.00 |
| D1330 |
|
51 |
51 |
$0.00 |