| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
2,003 |
1,798 |
$442K |
| D1206 |
Topical application of fluoride varnish |
486 |
486 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
245 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
667 |
667 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
127 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
237 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
44 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
362 |
362 |
$0.00 |
| D1120 |
Prophylaxis - child |
306 |
306 |
$0.00 |
| D1110 |
Prophylaxis - adult |
622 |
622 |
$0.00 |
| D9110 |
|
182 |
180 |
$0.00 |
| D0330 |
Panoramic radiographic image |
187 |
187 |
$0.00 |