| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,342 |
1,736 |
$224K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,419 |
615 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
3,828 |
3,823 |
$158K |
| D2140 |
|
2,827 |
1,433 |
$154K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,614 |
1,434 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,439 |
2,436 |
$141K |
| D1120 |
Prophylaxis - child |
4,289 |
4,285 |
$126K |
| D2330 |
|
1,583 |
702 |
$121K |
| D1110 |
Prophylaxis - adult |
1,357 |
1,355 |
$108K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26,623 |
4,997 |
$105K |
| D0210 |
Intraoral - complete series of radiographic images |
1,464 |
1,464 |
$68K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
660 |
332 |
$66K |
| D2954 |
|
578 |
395 |
$60K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
127 |
114 |
$59K |
| D0350 |
|
4,062 |
1,870 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,348 |
1,347 |
$28K |
| D0272 |
Bitewings - two radiographic images |
2,245 |
2,241 |
$26K |
| D2931 |
|
205 |
146 |
$26K |
| D2160 |
|
261 |
206 |
$21K |
| D9993 |
|
289 |
289 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,395 |
1,395 |
$16K |
| D1351 |
Sealant - per tooth |
706 |
179 |
$15K |
| D1310 |
|
290 |
289 |
$13K |
| D3310 |
|
31 |
16 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$9K |
| D4341 |
|
111 |
30 |
$7K |
| D1206 |
Topical application of fluoride varnish |
539 |
539 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
20 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
167 |
$2K |
| D0603 |
|
74 |
74 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$392.00 |