| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
349 |
202 |
$61K |
| D1120 |
Prophylaxis - child |
915 |
893 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,074 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,298 |
1,256 |
$54K |
| D1351 |
Sealant - per tooth |
616 |
183 |
$36K |
| D0274 |
Bitewings - four radiographic images |
555 |
533 |
$35K |
| D0272 |
Bitewings - two radiographic images |
776 |
756 |
$34K |
| D1110 |
Prophylaxis - adult |
375 |
355 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
219 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
465 |
448 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
202 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
25 |
$8K |
| D2140 |
|
35 |
25 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
18 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
14 |
$1K |