| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,058 |
879 |
$135K |
| D2740 |
Crown - porcelain/ceramic |
284 |
177 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,448 |
1,438 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
1,115 |
1,110 |
$76K |
| D2160 |
|
767 |
371 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
1,064 |
1,060 |
$50K |
| D1120 |
Prophylaxis - child |
1,061 |
1,058 |
$45K |
| D1110 |
Prophylaxis - adult |
463 |
462 |
$40K |
| D9430 |
|
1,103 |
964 |
$35K |
| D4910 |
|
463 |
456 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,063 |
2,050 |
$32K |
| D2140 |
|
541 |
288 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,691 |
1,280 |
$24K |
| D0350 |
|
2,070 |
993 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
148 |
75 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
891 |
849 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
15 |
$9K |
| D0274 |
Bitewings - four radiographic images |
388 |
388 |
$8K |
| D4341 |
|
40 |
12 |
$3K |
| D2330 |
|
38 |
15 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
12 |
$2K |
| D4342 |
|
35 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
36 |
13 |
$1K |
| D9993 |
|
12 |
12 |
$780.00 |
| D1310 |
|
12 |
12 |
$552.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$120.00 |