| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,731 |
1,527 |
$83K |
| D1206 |
Topical application of fluoride varnish |
1,746 |
1,534 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
959 |
839 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,659 |
1,450 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
521 |
460 |
$14K |
| D1351 |
Sealant - per tooth |
733 |
99 |
$14K |
| D0274 |
Bitewings - four radiographic images |
491 |
436 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,891 |
1,362 |
$10K |
| D0272 |
Bitewings - two radiographic images |
446 |
399 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
175 |
$6K |
| D0999 |
Unspecified diagnostic procedure, by report |
91 |
91 |
$3K |
| D0603 |
|
567 |
517 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
112 |
112 |
$2K |
| D0350 |
|
990 |
808 |
$553.50 |
| D1999 |
|
25 |
25 |
$375.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$246.00 |
| D0602 |
|
26 |
26 |
$65.00 |