| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
79 |
78 |
$10K |
| D0272 |
Bitewings - two radiographic images |
83 |
82 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
215 |
214 |
$6K |
| D1351 |
Sealant - per tooth |
218 |
54 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
64 |
34 |
$5K |
| D2140 |
|
61 |
39 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
15 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
172 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
275 |
275 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
176 |
160 |
$0.00 |
| D1120 |
Prophylaxis - child |
258 |
258 |
$0.00 |