| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
886 |
813 |
$395K |
| D2740 |
Crown - porcelain/ceramic |
795 |
660 |
$372K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,368 |
4,336 |
$286K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,427 |
719 |
$167K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,767 |
994 |
$114K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,247 |
4,131 |
$98K |
| D0274 |
Bitewings - four radiographic images |
3,373 |
3,339 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
853 |
852 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
647 |
452 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
917 |
558 |
$49K |
| D9430 |
|
1,443 |
1,410 |
$46K |
| D1120 |
Prophylaxis - child |
808 |
799 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
721 |
720 |
$34K |
| D1110 |
Prophylaxis - adult |
287 |
287 |
$25K |
| D4341 |
|
346 |
127 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,412 |
1,397 |
$22K |
| D2954 |
|
203 |
169 |
$21K |
| D4910 |
|
205 |
205 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,030 |
1,018 |
$12K |
| D0350 |
|
1,143 |
752 |
$11K |
| D0330 |
Panoramic radiographic image |
235 |
231 |
$7K |
| D1351 |
Sealant - per tooth |
151 |
46 |
$5K |
| D3320 |
|
12 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
161 |
160 |
$2K |
| D1310 |
|
14 |
14 |
$598.00 |