| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
987 |
735 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
407 |
$7K |
| D1120 |
Prophylaxis - child |
369 |
336 |
$6K |
| D1351 |
Sealant - per tooth |
157 |
79 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$1K |
| D1206 |
Topical application of fluoride varnish |
341 |
309 |
$990.60 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$458.64 |
| D0272 |
Bitewings - two radiographic images |
195 |
179 |
$278.70 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$120.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$96.38 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |