| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
512 |
481 |
$18K |
| D1206 |
Topical application of fluoride varnish |
298 |
283 |
$17K |
| D0330 |
Panoramic radiographic image |
248 |
235 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
279 |
263 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
205 |
$11K |
| D1351 |
Sealant - per tooth |
272 |
77 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
163 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
184 |
$7K |
| D0999 |
Unspecified diagnostic procedure, by report |
45 |
40 |
$6K |
| D0272 |
Bitewings - two radiographic images |
154 |
146 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
17 |
$389.58 |
| D0274 |
Bitewings - four radiographic images |
83 |
77 |
$244.00 |
| D1330 |
|
255 |
228 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
35 |
25 |
$0.00 |