| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,168 |
391 |
$48K |
| D2140 |
|
776 |
226 |
$32K |
| D1120 |
Prophylaxis - child |
895 |
744 |
$27K |
| D1206 |
Topical application of fluoride varnish |
708 |
658 |
$21K |
| D7111 |
|
686 |
143 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
669 |
574 |
$17K |
| D0274 |
Bitewings - four radiographic images |
965 |
798 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,798 |
1,359 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,892 |
1,543 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
983 |
807 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
243 |
222 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
274 |
$7K |
| D1110 |
Prophylaxis - adult |
86 |
80 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
271 |
190 |
$1K |
| D1999 |
|
50 |
50 |
$750.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$553.40 |
| D9999 |
Unspecified adjunctive procedure, by report |
47 |
47 |
$470.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$180.00 |
| D1352 |
|
86 |
15 |
$112.75 |
| D0601 |
|
27 |
24 |
$65.00 |
| D0415 |
|
84 |
29 |
$56.00 |
| D0460 |
|
65 |
17 |
$20.50 |
| D0602 |
|
16 |
14 |
$5.00 |
| D0425 |
|
84 |
29 |
$0.00 |