| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,138 |
1,067 |
$115K |
| D1206 |
Topical application of fluoride varnish |
7,288 |
5,247 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
6,015 |
4,363 |
$102K |
| D1120 |
Prophylaxis - child |
5,076 |
3,611 |
$102K |
| D1110 |
Prophylaxis - adult |
2,880 |
2,146 |
$96K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,180 |
359 |
$66K |
| D0330 |
Panoramic radiographic image |
1,343 |
1,055 |
$61K |
| D0274 |
Bitewings - four radiographic images |
3,097 |
2,285 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,938 |
1,493 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
1,729 |
1,412 |
$39K |
| D0272 |
Bitewings - two radiographic images |
3,021 |
2,114 |
$30K |
| D2140 |
|
716 |
340 |
$29K |
| D2335 |
|
107 |
38 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
93 |
81 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,797 |
1,381 |
$9K |
| D2160 |
|
95 |
65 |
$6K |
| D5110 |
|
14 |
14 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
68 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
57 |
$550.00 |