| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,988 |
2,942 |
$181K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
255 |
226 |
$116K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
159 |
118 |
$73K |
| D0210 |
Intraoral - complete series of radiographic images |
1,757 |
1,732 |
$68K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
594 |
269 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,146 |
1,136 |
$63K |
| D1110 |
Prophylaxis - adult |
565 |
562 |
$42K |
| D1120 |
Prophylaxis - child |
949 |
936 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,738 |
1,719 |
$31K |
| D9430 |
|
944 |
924 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
432 |
215 |
$28K |
| D4341 |
|
420 |
130 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,319 |
1,310 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,451 |
2,333 |
$18K |
| D3320 |
|
31 |
29 |
$11K |
| D4910 |
|
123 |
123 |
$8K |
| D3348 |
|
14 |
12 |
$6K |
| D0330 |
Panoramic radiographic image |
226 |
220 |
$6K |
| D2954 |
|
55 |
41 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
697 |
683 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
50 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
241 |
234 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
26 |
$4K |
| D9999 |
Unspecified adjunctive procedure, by report |
26 |
26 |
$3K |
| D1351 |
Sealant - per tooth |
76 |
13 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
52 |
51 |
$381.00 |