| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,309 |
1,193 |
$225K |
| D1206 |
Topical application of fluoride varnish |
1,826 |
1,691 |
$184K |
| D1208 |
Topical application of fluoride, excluding varnish |
544 |
540 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
180 |
$35K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
482 |
462 |
$8K |
| D0274 |
Bitewings - four radiographic images |
229 |
227 |
$7K |
| D1351 |
Sealant - per tooth |
834 |
173 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D0272 |
Bitewings - two radiographic images |
163 |
163 |
$2K |
| D1354 |
|
79 |
20 |
$513.48 |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
65 |
$270.65 |
| D0999 |
Unspecified diagnostic procedure, by report |
948 |
918 |
$0.00 |
| D0602 |
|
96 |
95 |
$0.00 |
| D0603 |
|
359 |
318 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
24 |
$0.00 |
| D0191 |
|
161 |
160 |
$0.00 |