| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
146 |
69 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$7K |
| D1351 |
Sealant - per tooth |
180 |
50 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
17 |
$6K |
| D2140 |
|
78 |
39 |
$4K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D2160 |
|
38 |
20 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$2K |
| D0350 |
|
68 |
65 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
64 |
64 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
69 |
$973.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$372.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$192.00 |