| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0999 |
Unspecified diagnostic procedure, by report |
4,197 |
3,849 |
$745K |
| D0120 |
Periodic oral evaluation - established patient |
1,317 |
1,301 |
$27K |
| D1206 |
Topical application of fluoride varnish |
665 |
650 |
$14K |
| D1110 |
Prophylaxis - adult |
324 |
324 |
$12K |
| D4910 |
|
235 |
205 |
$10K |
| D0274 |
Bitewings - four radiographic images |
192 |
191 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$684.62 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$473.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$166.60 |