| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
696 |
672 |
$16K |
| D1120 |
Prophylaxis - child |
679 |
655 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
597 |
570 |
$7K |
| D1206 |
Topical application of fluoride varnish |
141 |
140 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
22 |
22 |
$3K |
| D1351 |
Sealant - per tooth |
134 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
122 |
121 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
175 |
$937.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
228 |
160 |
$463.20 |
| D0601 |
|
14 |
14 |
$0.00 |