| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
1,099 |
992 |
$201K |
| D1120 |
Prophylaxis - child |
395 |
394 |
$500.37 |
| D1206 |
Topical application of fluoride varnish |
506 |
505 |
$357.12 |
| D1110 |
Prophylaxis - adult |
416 |
416 |
$238.61 |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$179.88 |
| D0120 |
Periodic oral evaluation - established patient |
245 |
245 |
$102.84 |
| D0274 |
Bitewings - four radiographic images |
221 |
221 |
$92.16 |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
328 |
$90.42 |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$69.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
193 |
$46.26 |