| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0160 |
|
193 |
193 |
$6K |
| D9995 |
|
193 |
193 |
$5K |
| D1120 |
Prophylaxis - child |
307 |
307 |
$2K |
| D1351 |
Sealant - per tooth |
53 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
56 |
56 |
$1K |
| D0272 |
Bitewings - two radiographic images |
300 |
300 |
$792.00 |
| D1310 |
|
49 |
49 |
$506.00 |
| D1330 |
|
45 |
45 |
$450.00 |
| D0602 |
|
89 |
89 |
$380.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$320.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,129 |
1,129 |
$290.00 |
| D0601 |
|
60 |
60 |
$245.00 |
| D0603 |
|
18 |
18 |
$80.00 |
| D1110 |
Prophylaxis - adult |
759 |
759 |
$60.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,151 |
1,147 |
$40.00 |
| D0274 |
Bitewings - four radiographic images |
595 |
595 |
$28.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,000 |
1,000 |
$27.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
238 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$0.00 |