| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| T1015 |
Clinic visit/encounter, all-inclusive |
624 |
608 |
$278K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
128 |
$0.00 |
| D1120 |
Prophylaxis - child |
413 |
413 |
$0.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
366 |
366 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
335 |
335 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
106 |
106 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
107 |
$0.00 |
| D1351 |
Sealant - per tooth |
138 |
16 |
$0.00 |