| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
699 |
691 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
1,115 |
1,106 |
$78K |
| D1120 |
Prophylaxis - child |
1,754 |
1,735 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,749 |
1,730 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$9K |
| D9248 |
|
16 |
16 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
143 |
50 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
96 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
268 |
265 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
131 |
$297.27 |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
12 |
$142.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$0.00 |