| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
629 |
442 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
564 |
364 |
$40K |
| D1120 |
Prophylaxis - child |
514 |
514 |
$21K |
| D1110 |
Prophylaxis - adult |
620 |
620 |
$20K |
| D2140 |
|
408 |
314 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
845 |
844 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
324 |
323 |
$18K |
| D2160 |
|
237 |
185 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
560 |
560 |
$14K |
| D0274 |
Bitewings - four radiographic images |
412 |
412 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
352 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
365 |
353 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
746 |
719 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
13 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
319 |
226 |
$2K |
| D7111 |
|
16 |
13 |
$1K |
| D2330 |
|
16 |
12 |
$703.82 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$325.00 |