| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
84 |
84 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
128 |
128 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
115 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
63 |
$873.03 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$400.40 |