| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,606 |
1,021 |
$170K |
| D0120 |
Periodic oral evaluation - established patient |
2,826 |
2,815 |
$143K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,933 |
1,926 |
$118K |
| D2160 |
|
1,501 |
662 |
$117K |
| D1120 |
Prophylaxis - child |
3,144 |
3,131 |
$111K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
227 |
132 |
$101K |
| D0210 |
Intraoral - complete series of radiographic images |
1,917 |
1,912 |
$84K |
| D0274 |
Bitewings - four radiographic images |
1,740 |
1,734 |
$35K |
| D1206 |
Topical application of fluoride varnish |
3,158 |
3,146 |
$34K |
| D4341 |
|
331 |
86 |
$21K |
| D0350 |
|
2,130 |
547 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
32 |
25 |
$13K |
| D0330 |
Panoramic radiographic image |
375 |
371 |
$11K |
| D9430 |
|
281 |
264 |
$9K |
| D2954 |
|
58 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
486 |
451 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,215 |
448 |
$4K |
| D4910 |
|
57 |
57 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$4K |
| D1320 |
|
226 |
224 |
$3K |
| D1351 |
Sealant - per tooth |
33 |
13 |
$1K |
| D2140 |
|
19 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$812.00 |
| D9110 |
|
12 |
12 |
$708.75 |
| D1310 |
|
27 |
26 |
$46.00 |