| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
593 |
568 |
$275K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,816 |
832 |
$212K |
| D9430 |
|
4,077 |
3,997 |
$130K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,413 |
1,411 |
$92K |
| D0274 |
Bitewings - four radiographic images |
2,882 |
2,872 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,199 |
1,197 |
$57K |
| D2740 |
Crown - porcelain/ceramic |
86 |
73 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,434 |
3,510 |
$31K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
52 |
43 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
271 |
152 |
$18K |
| D0330 |
Panoramic radiographic image |
407 |
405 |
$12K |
| D2954 |
|
114 |
93 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
103 |
$12K |
| D3320 |
|
30 |
25 |
$11K |
| D8670 |
Periodic orthodontic treatment visit |
37 |
37 |
$10K |
| D7240 |
Removal of impacted tooth - completely bony |
43 |
14 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
148 |
$7K |
| D7230 |
|
31 |
13 |
$6K |
| D1206 |
Topical application of fluoride varnish |
457 |
457 |
$5K |
| D1120 |
Prophylaxis - child |
178 |
178 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
355 |
346 |
$4K |
| D4341 |
|
45 |
13 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$3K |
| D4910 |
|
25 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$873.60 |
| D0350 |
|
12 |
12 |
$115.20 |
| D0999 |
Unspecified diagnostic procedure, by report |
31 |
31 |
$92.00 |