| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
183 |
139 |
$109K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,208 |
266 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
921 |
438 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
597 |
323 |
$69K |
| D2752 |
|
118 |
38 |
$66K |
| D2394 |
|
271 |
151 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
507 |
242 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
624 |
587 |
$38K |
| D3310 |
|
70 |
32 |
$37K |
| D3320 |
|
70 |
56 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
989 |
940 |
$30K |
| D5110 |
|
38 |
32 |
$22K |
| D1110 |
Prophylaxis - adult |
524 |
512 |
$18K |
| D2952 |
|
79 |
26 |
$18K |
| D2332 |
|
131 |
81 |
$15K |
| D5120 |
|
19 |
19 |
$13K |
| D5214 |
|
12 |
12 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
497 |
492 |
$9K |
| D1206 |
Topical application of fluoride varnish |
383 |
383 |
$6K |
| D0274 |
Bitewings - four radiographic images |
216 |
208 |
$5K |
| D2331 |
|
40 |
30 |
$4K |
| D2954 |
|
25 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
71 |
67 |
$2K |
| D2330 |
|
14 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
47 |
$798.80 |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
134 |
$731.50 |
| D0350 |
|
13 |
13 |
$154.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
14 |
$120.00 |