| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
363 |
124 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
93 |
$19K |
| D2140 |
|
301 |
101 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
520 |
516 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
270 |
104 |
$11K |
| D2160 |
|
104 |
49 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
31 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
47 |
$6K |
| D2332 |
|
43 |
13 |
$5K |
| D2931 |
|
18 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
255 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$742.95 |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$682.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
135 |
$537.36 |