| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
111 |
101 |
$91K |
| D1110 |
Prophylaxis - adult |
1,801 |
1,780 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,847 |
1,832 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,681 |
2,555 |
$24K |
| D0274 |
Bitewings - four radiographic images |
917 |
908 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,666 |
1,572 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
59 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
574 |
572 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
394 |
378 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
191 |
186 |
$6K |
| D1120 |
Prophylaxis - child |
151 |
151 |
$5K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$5K |
| D1351 |
Sealant - per tooth |
61 |
15 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
89 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$2K |
| D9920 |
|
13 |
12 |
$890.50 |
| D9994 |
|
114 |
114 |
$0.00 |
| D9310 |
|
15 |
15 |
$0.00 |