| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
210 |
209 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
255 |
$2K |
| D0272 |
Bitewings - two radiographic images |
149 |
147 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
94 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
46 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
177 |
$879.20 |
| D2140 |
|
36 |
27 |
$755.76 |
| D1120 |
Prophylaxis - child |
43 |
43 |
$649.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
157 |
$598.40 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$349.59 |