| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
164 |
164 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
121 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
192 |
192 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
344 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
73 |
$889.00 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$749.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$675.00 |