| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,518 |
1,649 |
$299K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,659 |
4,635 |
$293K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
483 |
341 |
$229K |
| D0120 |
Periodic oral evaluation - established patient |
3,635 |
3,617 |
$193K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,367 |
436 |
$161K |
| D0230 |
Intraoral - periapical each additional radiographic image |
34,359 |
6,099 |
$125K |
| D1120 |
Prophylaxis - child |
3,440 |
3,423 |
$120K |
| D2140 |
|
2,085 |
987 |
$111K |
| D1110 |
Prophylaxis - adult |
1,244 |
1,232 |
$108K |
| D0210 |
Intraoral - complete series of radiographic images |
2,279 |
2,264 |
$107K |
| D9430 |
|
2,059 |
1,881 |
$66K |
| D1351 |
Sealant - per tooth |
2,498 |
557 |
$52K |
| D0350 |
|
5,162 |
1,409 |
$49K |
| D0272 |
Bitewings - two radiographic images |
3,860 |
3,844 |
$44K |
| D2954 |
|
320 |
264 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,959 |
2,945 |
$28K |
| D0330 |
Panoramic radiographic image |
1,459 |
1,446 |
$24K |
| D2160 |
|
202 |
141 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,383 |
1,364 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
222 |
93 |
$12K |
| D4910 |
|
150 |
150 |
$12K |
| D4341 |
|
136 |
42 |
$10K |
| D9993 |
|
40 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
356 |
352 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
13 |
$2K |
| D1310 |
|
65 |
65 |
$2K |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
15 |
$140.00 |
| D1330 |
|
19 |
19 |
$0.00 |