| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
1,284 |
1,119 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
1,583 |
1,457 |
$18K |
| D1120 |
Prophylaxis - child |
1,697 |
1,566 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,693 |
1,561 |
$10K |
| D0603 |
|
159 |
156 |
$1K |
| D1351 |
Sealant - per tooth |
274 |
192 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
416 |
$208.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
331 |
294 |
$206.80 |
| D0601 |
|
26 |
26 |
$177.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$0.00 |
| D0602 |
|
45 |
42 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
392 |
370 |
$0.00 |