| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,023 |
416 |
$48K |
| D1110 |
Prophylaxis - adult |
927 |
837 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,618 |
1,500 |
$25K |
| D1120 |
Prophylaxis - child |
957 |
895 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
301 |
267 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
518 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
957 |
875 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
174 |
$12K |
| D2160 |
|
204 |
100 |
$11K |
| D0274 |
Bitewings - four radiographic images |
592 |
536 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
263 |
230 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
749 |
299 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
746 |
648 |
$3K |
| D1206 |
Topical application of fluoride varnish |
157 |
148 |
$2K |
| D1351 |
Sealant - per tooth |
44 |
14 |
$968.00 |
| D0272 |
Bitewings - two radiographic images |
103 |
100 |
$940.00 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$509.52 |
| D4910 |
|
13 |
12 |
$348.47 |