| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
299 |
299 |
$29K |
| D7240 |
Removal of impacted tooth - completely bony |
38 |
12 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
38 |
24 |
$3K |
| D9239 |
|
13 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
294 |
294 |
$956.22 |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
228 |
$303.51 |
| D1206 |
Topical application of fluoride varnish |
321 |
321 |
$112.53 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$91.30 |
| D0272 |
Bitewings - two radiographic images |
165 |
165 |
$88.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
196 |
190 |
$9.42 |
| D9243 |
|
35 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$0.00 |