| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,929 |
1,929 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
2,081 |
2,081 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,985 |
1,985 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,609 |
1,607 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,221 |
2,209 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
126 |
126 |
$666.76 |
| D0470 |
|
14 |
14 |
$280.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$131.34 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$91.47 |