| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
249 |
248 |
$4K |
| D1120 |
Prophylaxis - child |
99 |
99 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
101 |
$2K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
13 |
$1K |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
61 |
41 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$966.00 |
| D1330 |
|
279 |
274 |
$831.50 |
| D0120 |
Periodic oral evaluation - established patient |
26 |
26 |
$732.00 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$336.00 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
61 |
39 |
$210.00 |
| 90460 |
Immunization administration through 18 years of age via any route, first or only component |
28 |
28 |
$208.00 |
| 99214 |
Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity |
17 |
14 |
$185.04 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$90.00 |
| 3008F |
|
500 |
399 |
$0.00 |
| 2001F |
|
661 |
522 |
$0.00 |
| 2000F |
|
460 |
367 |
$0.00 |
| 3074F |
|
438 |
367 |
$0.00 |
| 1000F |
|
175 |
130 |
$0.00 |
| 1126F |
|
87 |
71 |
$0.00 |
| 1160F |
|
426 |
337 |
$0.00 |
| 3078F |
|
438 |
353 |
$0.00 |
| 1159F |
|
426 |
337 |
$0.00 |