| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
899 |
359 |
$59K |
| D1351 |
Sealant - per tooth |
2,742 |
757 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,667 |
1,667 |
$56K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
476 |
155 |
$50K |
| D1120 |
Prophylaxis - child |
1,696 |
1,696 |
$49K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
412 |
136 |
$41K |
| D7240 |
Removal of impacted tooth - completely bony |
168 |
62 |
$38K |
| D2140 |
|
565 |
255 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
513 |
245 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,441 |
1,428 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
669 |
666 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,764 |
1,763 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
268 |
268 |
$10K |
| D2160 |
|
101 |
71 |
$8K |
| D0272 |
Bitewings - two radiographic images |
824 |
824 |
$8K |
| D0330 |
Panoramic radiographic image |
254 |
253 |
$6K |
| D0350 |
|
595 |
516 |
$6K |
| D2330 |
|
61 |
38 |
$5K |
| D0274 |
Bitewings - four radiographic images |
265 |
265 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
127 |
127 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
99 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
299 |
$3K |
| D9430 |
|
75 |
73 |
$2K |
| D1110 |
Prophylaxis - adult |
16 |
15 |
$560.00 |