| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
182 |
168 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,629 |
2,504 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
4,007 |
3,719 |
$55K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
94 |
67 |
$45K |
| D1120 |
Prophylaxis - child |
2,597 |
2,442 |
$36K |
| D1206 |
Topical application of fluoride varnish |
3,833 |
3,680 |
$33K |
| D9430 |
|
2,446 |
2,178 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
6,599 |
5,843 |
$26K |
| D1110 |
Prophylaxis - adult |
913 |
879 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
1,132 |
1,082 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,258 |
4,854 |
$13K |
| D0274 |
Bitewings - four radiographic images |
2,126 |
2,002 |
$13K |
| D3320 |
|
15 |
12 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
544 |
355 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
181 |
97 |
$7K |
| D0272 |
Bitewings - two radiographic images |
1,056 |
968 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
136 |
$2K |
| D1351 |
Sealant - per tooth |
436 |
137 |
$2K |
| D9110 |
|
327 |
252 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
45 |
45 |
$2K |
| D0270 |
|
921 |
865 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
14 |
14 |
$840.00 |
| D4341 |
|
86 |
39 |
$820.00 |
| D1310 |
|
182 |
166 |
$736.00 |
| D0140 |
Limited oral evaluation - problem focused |
259 |
232 |
$700.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
203 |
26 |
$315.80 |
| D9993 |
|
123 |
111 |
$195.00 |
| D0601 |
|
176 |
158 |
$48.00 |
| D1999 |
|
372 |
289 |
$10.00 |
| D1330 |
|
6,360 |
5,733 |
$0.00 |
| D9995 |
|
16 |
15 |
$0.00 |