| Code | Description | Claims | Beneficiaries | Total Paid |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20,227 |
5,049 |
$2.93M |
| D1120 |
Prophylaxis - child |
41,484 |
40,890 |
$1.53M |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14,625 |
5,982 |
$1.44M |
| D0120 |
Periodic oral evaluation - established patient |
48,072 |
47,404 |
$1.39M |
| D1208 |
Topical application of fluoride, excluding varnish |
52,981 |
52,222 |
$1.11M |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12,754 |
5,891 |
$931K |
| D1110 |
Prophylaxis - adult |
15,867 |
15,648 |
$803K |
| D0330 |
Panoramic radiographic image |
10,900 |
10,780 |
$654K |
| D9248 |
|
5,245 |
4,932 |
$648K |
| D0272 |
Bitewings - two radiographic images |
29,434 |
28,999 |
$647K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
6,253 |
2,894 |
$632K |
| D1351 |
Sealant - per tooth |
18,531 |
5,605 |
$565K |
| D7140 |
Extraction, erupted tooth or exposed root |
7,242 |
3,917 |
$522K |
| D2390 |
|
1,476 |
753 |
$356K |
| D0210 |
Intraoral - complete series of radiographic images |
5,190 |
5,099 |
$344K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,319 |
5,242 |
$263K |
| D7240 |
Removal of impacted tooth - completely bony |
1,066 |
309 |
$250K |
| D0145 |
Oral evaluation for a patient under three years of age |
4,694 |
4,650 |
$238K |
| D0220 |
Intraoral - periapical first radiographic image |
14,356 |
13,928 |
$220K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,614 |
1,021 |
$203K |
| D2330 |
|
1,484 |
887 |
$123K |
| D0140 |
Limited oral evaluation - problem focused |
4,483 |
4,347 |
$64K |
| D2331 |
|
258 |
165 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
597 |
555 |
$25K |
| D3110 |
|
531 |
330 |
$20K |
| D9239 |
|
391 |
257 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
749 |
680 |
$10K |
| D9222 |
|
80 |
68 |
$9K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
68 |
53 |
$6K |
| D2332 |
|
17 |
14 |
$2K |
| D9920 |
|
57 |
57 |
$70.10 |