| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
804 |
731 |
$424K |
| D2740 |
Crown - porcelain/ceramic |
292 |
155 |
$175K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,673 |
1,005 |
$147K |
| D1110 |
Prophylaxis - adult |
3,307 |
2,996 |
$140K |
| D0210 |
Intraoral - complete series of radiographic images |
1,202 |
1,063 |
$66K |
| D0140 |
Limited oral evaluation - problem focused |
2,153 |
1,895 |
$64K |
| D8670 |
Periodic orthodontic treatment visit |
280 |
274 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,204 |
783 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,793 |
1,565 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
686 |
523 |
$48K |
| D3320 |
|
57 |
50 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,076 |
998 |
$21K |
| D0274 |
Bitewings - four radiographic images |
516 |
485 |
$17K |
| D0330 |
Panoramic radiographic image |
233 |
185 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
946 |
842 |
$12K |
| D4341 |
|
55 |
30 |
$4K |
| D1351 |
Sealant - per tooth |
228 |
68 |
$4K |
| D2950 |
|
44 |
38 |
$4K |
| D0340 |
|
92 |
63 |
$4K |
| D4342 |
|
126 |
66 |
$4K |
| D1120 |
Prophylaxis - child |
105 |
91 |
$3K |
| D0270 |
|
117 |
102 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$700.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
26 |
$466.00 |
| D4910 |
|
45 |
40 |
$136.00 |
| D0364 |
|
36 |
32 |
$50.00 |