| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
958 |
621 |
$453K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
224 |
203 |
$168K |
| D2950 |
|
797 |
525 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
490 |
300 |
$66K |
| D1110 |
Prophylaxis - adult |
1,010 |
987 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,067 |
1,042 |
$58K |
| D3320 |
|
78 |
65 |
$51K |
| D4341 |
|
411 |
183 |
$35K |
| D0330 |
Panoramic radiographic image |
768 |
754 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,086 |
1,075 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,269 |
1,247 |
$30K |
| D1206 |
Topical application of fluoride varnish |
723 |
715 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
115 |
53 |
$12K |
| D1120 |
Prophylaxis - child |
272 |
270 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
197 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
44 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
613 |
594 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
16 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
295 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$3K |
| D4910 |
|
27 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$912.00 |
| D1330 |
|
146 |
144 |
$864.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$368.00 |