| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
544 |
226 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
224 |
79 |
$23K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
229 |
80 |
$22K |
| D1120 |
Prophylaxis - child |
730 |
720 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
559 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
92 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
710 |
677 |
$11K |
| D1351 |
Sealant - per tooth |
531 |
144 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
242 |
239 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
922 |
908 |
$10K |
| D2140 |
|
112 |
60 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
272 |
$6K |
| D1110 |
Prophylaxis - adult |
106 |
104 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
251 |
$3K |
| D0350 |
|
214 |
193 |
$2K |
| D0272 |
Bitewings - two radiographic images |
209 |
203 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
76 |
75 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$1K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$775.00 |
| D9430 |
|
21 |
21 |
$588.00 |