| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
95 |
$2K |
| D1206 |
Topical application of fluoride varnish |
83 |
82 |
$732.51 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$474.49 |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
34 |
34 |
$137.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$124.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
59 |
$122.82 |
| 90672 |
|
33 |
32 |
$99.00 |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
13 |
13 |
$99.00 |
| D1330 |
|
150 |
149 |
$88.16 |
| 90473 |
|
37 |
36 |
$82.50 |
| 90686 |
|
17 |
17 |
$55.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$0.00 |