| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9999 |
Unspecified adjunctive procedure, by report |
390 |
257 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
445 |
415 |
$22K |
| D1120 |
Prophylaxis - child |
187 |
183 |
$8K |
| D0999 |
Unspecified diagnostic procedure, by report |
117 |
107 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$995.63 |
| D1206 |
Topical application of fluoride varnish |
176 |
173 |
$572.11 |
| D0274 |
Bitewings - four radiographic images |
69 |
68 |
$75.28 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |