| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
575 |
250 |
$10K |
| D2160 |
|
119 |
66 |
$5K |
| D1110 |
Prophylaxis - adult |
648 |
641 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
386 |
145 |
$4K |
| D1206 |
Topical application of fluoride varnish |
668 |
660 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
255 |
147 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
611 |
607 |
$2K |
| D0274 |
Bitewings - four radiographic images |
405 |
402 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
562 |
543 |
$2K |
| D1120 |
Prophylaxis - child |
303 |
303 |
$2K |
| D1351 |
Sealant - per tooth |
323 |
90 |
$1K |
| D0272 |
Bitewings - two radiographic images |
259 |
259 |
$1K |
| D0330 |
Panoramic radiographic image |
167 |
165 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
89 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
436 |
417 |
$738.46 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$700.52 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
56 |
52 |
$419.79 |
| D1330 |
|
12 |
12 |
$162.00 |
| D2331 |
|
105 |
64 |
$124.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
30 |
$35.52 |
| D2140 |
|
52 |
28 |
$0.00 |
| D2332 |
|
22 |
13 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
45 |
$0.00 |