| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
5,558 |
2,906 |
$368K |
| D0120 |
Periodic oral evaluation - established patient |
5,273 |
5,266 |
$292K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,611 |
1,347 |
$204K |
| D1120 |
Prophylaxis - child |
4,497 |
4,491 |
$167K |
| D1110 |
Prophylaxis - adult |
1,937 |
1,933 |
$165K |
| D9430 |
|
4,256 |
3,976 |
$135K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,011 |
2,001 |
$122K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27,795 |
7,954 |
$120K |
| D0274 |
Bitewings - four radiographic images |
4,684 |
4,679 |
$97K |
| D2160 |
|
1,162 |
801 |
$91K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,579 |
6,570 |
$68K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
534 |
263 |
$63K |
| D7240 |
Removal of impacted tooth - completely bony |
228 |
88 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
504 |
265 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
641 |
633 |
$29K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
62 |
52 |
$29K |
| D1351 |
Sealant - per tooth |
1,044 |
269 |
$26K |
| D0330 |
Panoramic radiographic image |
917 |
909 |
$24K |
| D2140 |
|
355 |
240 |
$18K |
| D4910 |
|
64 |
64 |
$5K |
| D0272 |
Bitewings - two radiographic images |
392 |
391 |
$4K |
| D2332 |
|
42 |
27 |
$3K |
| D4341 |
|
45 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
41 |
$3K |
| D1206 |
Topical application of fluoride varnish |
117 |
117 |
$2K |
| D0270 |
|
306 |
298 |
$2K |
| D0350 |
|
161 |
94 |
$1K |
| D9993 |
|
12 |
12 |
$715.00 |
| D1310 |
|
12 |
12 |
$506.00 |
| D1999 |
|
1,621 |
1,418 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$90.75 |
| D1330 |
|
50 |
50 |
$0.00 |