| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,955 |
1,445 |
$593K |
| D1120 |
Prophylaxis - child |
10,951 |
10,893 |
$528K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
7,324 |
2,724 |
$491K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
4,928 |
1,432 |
$488K |
| D0120 |
Periodic oral evaluation - established patient |
5,753 |
5,730 |
$401K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,107 |
5,072 |
$343K |
| D2140 |
|
5,777 |
2,523 |
$314K |
| D1310 |
|
6,387 |
6,358 |
$283K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,822 |
2,286 |
$276K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,451 |
12,373 |
$249K |
| D0230 |
Intraoral - periapical each additional radiographic image |
48,220 |
10,854 |
$215K |
| D1351 |
Sealant - per tooth |
4,979 |
1,816 |
$171K |
| D2160 |
|
1,845 |
951 |
$147K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,688 |
1,676 |
$115K |
| D0220 |
Intraoral - periapical first radiographic image |
9,559 |
9,498 |
$114K |
| D1110 |
Prophylaxis - adult |
1,341 |
1,333 |
$114K |
| D0603 |
|
6,212 |
6,182 |
$90K |
| D0350 |
|
7,299 |
3,116 |
$76K |
| D2330 |
|
777 |
483 |
$60K |
| D9993 |
|
699 |
694 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
884 |
880 |
$42K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
254 |
165 |
$30K |
| D4341 |
|
369 |
96 |
$26K |
| D1510 |
|
114 |
93 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,799 |
1,744 |
$21K |
| D2331 |
|
186 |
116 |
$15K |
| D1320 |
|
314 |
314 |
$5K |
| D4342 |
|
56 |
16 |
$2K |
| D9430 |
|
26 |
26 |
$816.00 |
| D0601 |
|
24 |
24 |
$330.00 |