| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
734 |
394 |
$25K |
| D2160 |
|
241 |
146 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
289 |
121 |
$10K |
| D1206 |
Topical application of fluoride varnish |
535 |
529 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
388 |
$6K |
| D1110 |
Prophylaxis - adult |
187 |
185 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
152 |
$2K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
65 |
$1K |
| D1120 |
Prophylaxis - child |
79 |
78 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$696.00 |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
169 |
$650.00 |
| D2331 |
|
62 |
43 |
$576.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$284.00 |
| D2940 |
|
31 |
26 |
$175.00 |
| D1354 |
|
1,422 |
540 |
$88.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
13 |
$78.00 |
| D1999 |
|
15 |
14 |
$56.00 |
| D1330 |
|
150 |
148 |
$10.00 |