| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
871 |
780 |
$22K |
| D0999 |
Unspecified diagnostic procedure, by report |
213 |
166 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
970 |
874 |
$16K |
| D1206 |
Topical application of fluoride varnish |
855 |
764 |
$13K |
| D0602 |
|
152 |
149 |
$2K |
| D0601 |
|
114 |
114 |
$2K |
| D1351 |
Sealant - per tooth |
27 |
15 |
$1K |
| D0603 |
|
105 |
105 |
$796.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$520.85 |
| D0220 |
Intraoral - periapical first radiographic image |
236 |
216 |
$102.63 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$0.00 |