| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
175 |
162 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
349 |
45 |
$14K |
| D1351 |
Sealant - per tooth |
322 |
64 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
309 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
27 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
302 |
298 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
64 |
$3K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
98 |
51 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
14 |
$2K |
| D2140 |
|
98 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
286 |
274 |
$89.50 |
| D1120 |
Prophylaxis - child |
361 |
354 |
$33.67 |
| D1206 |
Topical application of fluoride varnish |
359 |
351 |
$0.00 |