| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,069 |
989 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
2,629 |
2,613 |
$121K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
181 |
126 |
$86K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,260 |
3,925 |
$84K |
| D1120 |
Prophylaxis - child |
1,752 |
1,746 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
742 |
737 |
$48K |
| D0272 |
Bitewings - two radiographic images |
3,215 |
3,201 |
$36K |
| D2160 |
|
432 |
271 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,605 |
2,596 |
$28K |
| D2140 |
|
463 |
247 |
$24K |
| D1110 |
Prophylaxis - adult |
242 |
241 |
$21K |
| D0350 |
|
1,592 |
606 |
$15K |
| D4341 |
|
150 |
42 |
$10K |
| D2954 |
|
76 |
58 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
391 |
389 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
15 |
$924.00 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$720.00 |