| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
606 |
580 |
$107K |
| D0220 |
Intraoral - periapical first radiographic image |
1,051 |
1,000 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
685 |
157 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
983 |
964 |
$41K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
468 |
188 |
$24K |
| D2140 |
|
247 |
143 |
$12K |
| D0274 |
Bitewings - four radiographic images |
145 |
143 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
86 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
315 |
87 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
113 |
$3K |
| D1351 |
Sealant - per tooth |
102 |
25 |
$2K |
| D1120 |
Prophylaxis - child |
1,129 |
1,099 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,005 |
916 |
$1K |
| D1206 |
Topical application of fluoride varnish |
1,061 |
1,038 |
$0.00 |