| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,081 |
1,074 |
$40K |
| D0272 |
Bitewings - two radiographic images |
904 |
897 |
$39K |
| D1120 |
Prophylaxis - child |
1,270 |
1,263 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
209 |
81 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,378 |
1,374 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
297 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
29 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
168 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
15 |
$20.48 |