| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,975 |
1,029 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
2,108 |
2,104 |
$106K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
202 |
136 |
$96K |
| D1120 |
Prophylaxis - child |
2,015 |
2,012 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,937 |
2,923 |
$62K |
| D4910 |
|
565 |
565 |
$43K |
| D2140 |
|
785 |
419 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
664 |
664 |
$41K |
| D4341 |
|
491 |
132 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,701 |
2,695 |
$30K |
| D1110 |
Prophylaxis - adult |
309 |
309 |
$27K |
| D2160 |
|
246 |
156 |
$20K |
| D2954 |
|
177 |
120 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
83 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,160 |
1,158 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
270 |
270 |
$13K |
| D0274 |
Bitewings - four radiographic images |
539 |
539 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
46 |
$5K |
| D1351 |
Sealant - per tooth |
214 |
56 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
325 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D9430 |
|
52 |
52 |
$2K |
| D0350 |
|
80 |
40 |
$835.20 |