| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,166 |
1,389 |
$190K |
| D1120 |
Prophylaxis - child |
4,391 |
4,391 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
5,428 |
5,428 |
$151K |
| D2140 |
|
2,098 |
1,472 |
$145K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,185 |
5,185 |
$124K |
| D1110 |
Prophylaxis - adult |
2,141 |
2,141 |
$113K |
| D0274 |
Bitewings - four radiographic images |
2,334 |
2,334 |
$80K |
| D0220 |
Intraoral - periapical first radiographic image |
4,541 |
4,520 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,760 |
3,968 |
$72K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
294 |
208 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,055 |
1,055 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
445 |
307 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,496 |
1,496 |
$36K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
276 |
195 |
$32K |
| D1206 |
Topical application of fluoride varnish |
225 |
225 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$3K |
| D4355 |
|
12 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$946.00 |
| D0191 |
|
12 |
12 |
$168.00 |