| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
163 |
153 |
$28K |
| D9110 |
|
14 |
14 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$0.00 |
| D1120 |
Prophylaxis - child |
33 |
33 |
$0.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$0.00 |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$0.00 |