| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
579 |
573 |
$25K |
| D1206 |
Topical application of fluoride varnish |
376 |
375 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
411 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
471 |
467 |
$2K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
232 |
232 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
29 |
$708.75 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$656.25 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$405.00 |