| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
282 |
160 |
$25K |
| D2140 |
|
340 |
257 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
297 |
188 |
$19K |
| D1120 |
Prophylaxis - child |
580 |
580 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
783 |
783 |
$16K |
| D1206 |
Topical application of fluoride varnish |
941 |
941 |
$14K |
| D0274 |
Bitewings - four radiographic images |
463 |
463 |
$13K |
| D0330 |
Panoramic radiographic image |
220 |
220 |
$10K |
| D1110 |
Prophylaxis - adult |
234 |
234 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
246 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
24 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
87 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
84 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |