| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
2,479 |
2,467 |
$173K |
| D1206 |
Topical application of fluoride varnish |
2,694 |
2,687 |
$92K |
| D1120 |
Prophylaxis - child |
2,771 |
2,758 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
2,615 |
2,607 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
293 |
127 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,237 |
2,222 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
90 |
26 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,064 |
2,052 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
252 |
248 |
$5K |
| D2140 |
|
50 |
26 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
13 |
$4K |
| D1351 |
Sealant - per tooth |
60 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
111 |
111 |
$822.38 |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
184 |
$38.00 |