| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
945 |
482 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,445 |
1,445 |
$35K |
| D1120 |
Prophylaxis - child |
1,018 |
1,018 |
$24K |
| D1110 |
Prophylaxis - adult |
893 |
893 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,682 |
1,681 |
$18K |
| D0330 |
Panoramic radiographic image |
483 |
483 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
386 |
$9K |
| D0272 |
Bitewings - two radiographic images |
1,523 |
1,523 |
$9K |
| D2140 |
|
197 |
122 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,791 |
1,784 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,181 |
1,181 |
$8K |
| D2160 |
|
101 |
64 |
$5K |
| D7111 |
|
122 |
72 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
85 |
$3K |
| D0603 |
|
265 |
265 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$2K |
| D9920 |
|
42 |
42 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
14 |
$990.00 |
| D0601 |
|
31 |
31 |
$310.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$265.20 |
| D0602 |
|
12 |
12 |
$120.00 |