| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
97 |
97 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$882.50 |
| D0120 |
Periodic oral evaluation - established patient |
56 |
53 |
$693.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$580.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$304.10 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$267.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$150.15 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$149.40 |
| D1999 |
|
50 |
45 |
$130.00 |