| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,087 |
563 |
$250K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,458 |
1,255 |
$231K |
| D1120 |
Prophylaxis - child |
4,406 |
4,389 |
$218K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,134 |
564 |
$212K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,444 |
2,429 |
$163K |
| D0120 |
Periodic oral evaluation - established patient |
1,848 |
1,847 |
$129K |
| D2140 |
|
2,317 |
1,032 |
$126K |
| D1310 |
|
2,748 |
2,736 |
$122K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,015 |
928 |
$115K |
| D1351 |
Sealant - per tooth |
2,850 |
944 |
$106K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,976 |
4,957 |
$105K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,655 |
4,182 |
$84K |
| D2160 |
|
915 |
435 |
$73K |
| D0145 |
Oral evaluation for a patient under three years of age |
854 |
852 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,356 |
3,336 |
$40K |
| D1110 |
Prophylaxis - adult |
478 |
477 |
$40K |
| D0603 |
|
2,730 |
2,717 |
$39K |
| D0350 |
|
3,418 |
1,330 |
$35K |
| D2330 |
|
220 |
129 |
$17K |
| D2331 |
|
155 |
92 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
262 |
260 |
$12K |
| D0272 |
Bitewings - two radiographic images |
950 |
947 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
37 |
$7K |
| D1510 |
|
15 |
14 |
$3K |
| D1320 |
|
138 |
138 |
$2K |
| D4342 |
|
41 |
12 |
$2K |
| D9430 |
|
26 |
26 |
$832.00 |