| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
496 |
323 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,743 |
1,716 |
$55K |
| D1120 |
Prophylaxis - child |
1,303 |
1,282 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,392 |
1,363 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
323 |
165 |
$33K |
| D0274 |
Bitewings - four radiographic images |
799 |
788 |
$31K |
| D0330 |
Panoramic radiographic image |
434 |
425 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
168 |
$25K |
| D2140 |
|
250 |
185 |
$23K |
| D1110 |
Prophylaxis - adult |
320 |
313 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
295 |
$17K |
| D1351 |
Sealant - per tooth |
465 |
142 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
46 |
$13K |
| D0272 |
Bitewings - two radiographic images |
417 |
412 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
107 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
93 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
102 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$945.00 |