| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
735 |
692 |
$402K |
| D1110 |
Prophylaxis - adult |
4,668 |
4,668 |
$231K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,080 |
909 |
$213K |
| D2950 |
|
1,399 |
1,188 |
$175K |
| D0274 |
Bitewings - four radiographic images |
4,190 |
4,190 |
$114K |
| D2931 |
|
715 |
669 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,178 |
2,178 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,688 |
3,688 |
$83K |
| D0140 |
Limited oral evaluation - problem focused |
2,049 |
2,040 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,729 |
4,729 |
$77K |
| D0330 |
Panoramic radiographic image |
1,229 |
1,229 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
3,310 |
3,237 |
$42K |
| D9310 |
|
642 |
640 |
$42K |
| D1120 |
Prophylaxis - child |
1,097 |
1,097 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
268 |
123 |
$36K |
| D1351 |
Sealant - per tooth |
522 |
141 |
$15K |
| D0272 |
Bitewings - two radiographic images |
798 |
798 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
91 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
484 |
358 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
26 |
$812.50 |