| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
404 |
175 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,175 |
1,284 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
797 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
209 |
68 |
$22K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
215 |
71 |
$21K |
| D8670 |
Periodic orthodontic treatment visit |
87 |
84 |
$20K |
| D1120 |
Prophylaxis - child |
627 |
627 |
$19K |
| D0274 |
Bitewings - four radiographic images |
751 |
749 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
225 |
224 |
$10K |
| D2160 |
|
130 |
75 |
$10K |
| D2140 |
|
146 |
69 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
710 |
709 |
$7K |
| D4341 |
|
118 |
31 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
142 |
141 |
$5K |
| D7111 |
|
70 |
27 |
$4K |
| D1351 |
Sealant - per tooth |
158 |
55 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
14 |
$3K |
| D0350 |
|
271 |
126 |
$2K |
| D0272 |
Bitewings - two radiographic images |
152 |
151 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
102 |
$1K |
| D1110 |
Prophylaxis - adult |
22 |
21 |
$800.00 |