| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
382 |
336 |
$257K |
| D1110 |
Prophylaxis - adult |
2,447 |
2,390 |
$130K |
| D2740 |
Crown - porcelain/ceramic |
166 |
122 |
$121K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,128 |
731 |
$87K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
132 |
103 |
$78K |
| D0274 |
Bitewings - four radiographic images |
1,732 |
1,699 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,616 |
1,568 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
760 |
442 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
622 |
601 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,031 |
997 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,688 |
1,654 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,929 |
1,857 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
308 |
219 |
$27K |
| D2950 |
|
59 |
53 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
160 |
$5K |
| D1120 |
Prophylaxis - child |
77 |
76 |
$4K |
| D9110 |
|
101 |
100 |
$4K |
| D2954 |
|
17 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
102 |
$2K |