| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,090 |
2,001 |
$274K |
| D0120 |
Periodic oral evaluation - established patient |
4,161 |
4,148 |
$228K |
| D1120 |
Prophylaxis - child |
4,774 |
4,757 |
$186K |
| D2140 |
|
2,965 |
1,335 |
$161K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,195 |
2,187 |
$138K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
288 |
218 |
$137K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27,608 |
5,240 |
$111K |
| D0350 |
|
7,845 |
2,896 |
$80K |
| D1351 |
Sealant - per tooth |
2,328 |
697 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,202 |
5,180 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
1,181 |
1,179 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,257 |
2,243 |
$48K |
| D9430 |
|
1,473 |
1,426 |
$46K |
| D1110 |
Prophylaxis - adult |
452 |
449 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
372 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
233 |
154 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,274 |
2,248 |
$27K |
| D2954 |
|
237 |
181 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,387 |
1,383 |
$16K |
| D2160 |
|
204 |
151 |
$16K |
| D1310 |
|
319 |
317 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
13 |
$6K |
| D9993 |
|
102 |
102 |
$6K |
| D1206 |
Topical application of fluoride varnish |
164 |
164 |
$4K |
| D4341 |
|
46 |
14 |
$3K |
| D0601 |
|
91 |
91 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
13 |
$560.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |