| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
5,027 |
1,985 |
$336K |
| D1120 |
Prophylaxis - child |
5,815 |
5,796 |
$242K |
| D0120 |
Periodic oral evaluation - established patient |
4,046 |
4,031 |
$239K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,798 |
457 |
$213K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27,487 |
7,124 |
$191K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,475 |
2,471 |
$154K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,385 |
361 |
$137K |
| D2140 |
|
1,785 |
916 |
$97K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,652 |
717 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,416 |
6,395 |
$90K |
| D0350 |
|
4,408 |
2,341 |
$65K |
| D1351 |
Sealant - per tooth |
2,030 |
721 |
$61K |
| D1310 |
|
1,180 |
1,177 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,064 |
2,062 |
$44K |
| D2740 |
Crown - porcelain/ceramic |
77 |
53 |
$37K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
74 |
50 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,688 |
2,681 |
$32K |
| D2160 |
|
378 |
213 |
$30K |
| D4341 |
|
382 |
98 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,839 |
1,821 |
$22K |
| D9993 |
|
244 |
244 |
$15K |
| D0603 |
|
1,033 |
1,030 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
340 |
338 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
27 |
25 |
$13K |
| D2330 |
|
163 |
93 |
$12K |
| D9430 |
|
318 |
314 |
$10K |
| D2954 |
|
79 |
56 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
210 |
$7K |
| D3320 |
|
14 |
13 |
$5K |
| D0330 |
Panoramic radiographic image |
161 |
161 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$4K |
| D1320 |
|
126 |
126 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$545.00 |
| D0602 |
|
12 |
12 |
$180.00 |