| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,701 |
1,140 |
$498K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,378 |
1,433 |
$289K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,704 |
944 |
$282K |
| D1120 |
Prophylaxis - child |
10,589 |
10,484 |
$277K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,988 |
1,873 |
$241K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,746 |
13,445 |
$221K |
| D0120 |
Periodic oral evaluation - established patient |
9,941 |
9,853 |
$184K |
| D1206 |
Topical application of fluoride varnish |
11,382 |
11,259 |
$182K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,382 |
1,709 |
$175K |
| D0220 |
Intraoral - periapical first radiographic image |
14,495 |
14,222 |
$159K |
| D9630 |
|
5,078 |
4,776 |
$139K |
| D9920 |
|
2,406 |
1,680 |
$130K |
| D1351 |
Sealant - per tooth |
3,886 |
1,773 |
$117K |
| D0274 |
Bitewings - four radiographic images |
4,135 |
4,089 |
$111K |
| D2934 |
|
857 |
255 |
$105K |
| D2940 |
|
1,929 |
591 |
$91K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,469 |
1,218 |
$91K |
| D0272 |
Bitewings - two radiographic images |
4,890 |
4,838 |
$86K |
| D9410 |
|
173 |
165 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,956 |
2,908 |
$80K |
| D1110 |
Prophylaxis - adult |
2,234 |
2,201 |
$58K |
| D9999 |
Unspecified adjunctive procedure, by report |
128 |
109 |
$51K |
| D9248 |
|
587 |
578 |
$48K |
| D0330 |
Panoramic radiographic image |
940 |
927 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
2,126 |
2,055 |
$44K |
| D1515 |
|
187 |
139 |
$31K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,693 |
1,513 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
407 |
174 |
$25K |
| D1510 |
|
144 |
119 |
$22K |
| D9110 |
|
277 |
260 |
$11K |
| D9610 |
|
225 |
218 |
$9K |
| D9310 |
|
140 |
135 |
$7K |
| D0240 |
|
196 |
196 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
191 |
181 |
$3K |
| D1516 |
|
16 |
16 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
207 |
$3K |