| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
697 |
649 |
$120K |
| D1110 |
Prophylaxis - adult |
152 |
152 |
$403.95 |
| D1206 |
Topical application of fluoride varnish |
166 |
166 |
$350.42 |
| D1120 |
Prophylaxis - child |
93 |
93 |
$211.33 |
| D0120 |
Periodic oral evaluation - established patient |
217 |
217 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
56 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
47 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$0.00 |