| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
141 |
141 |
$6K |
| D1206 |
Topical application of fluoride varnish |
202 |
202 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
197 |
197 |
$5K |
| D0274 |
Bitewings - four radiographic images |
214 |
214 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
314 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
237 |
$903.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$675.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$325.00 |