| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
575 |
412 |
$476K |
| D1110 |
Prophylaxis - adult |
3,072 |
3,072 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
3,229 |
3,229 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,973 |
2,973 |
$65K |
| D2954 |
|
391 |
348 |
$60K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
128 |
125 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,104 |
3,083 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,398 |
2,398 |
$25K |
| D0330 |
Panoramic radiographic image |
404 |
404 |
$11K |
| D1120 |
Prophylaxis - child |
334 |
334 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
641 |
632 |
$10K |
| D3320 |
|
26 |
25 |
$8K |
| D9110 |
|
331 |
327 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
84 |
$6K |
| D2790 |
|
14 |
13 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
86 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
307 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$3K |
| D9310 |
|
33 |
33 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
27 |
$2K |
| D1351 |
Sealant - per tooth |
13 |
12 |
$1K |
| D9995 |
|
17 |
17 |
$399.16 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$322.20 |