| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
284 |
214 |
$163K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
239 |
227 |
$153K |
| D1110 |
Prophylaxis - adult |
2,630 |
2,581 |
$105K |
| D2950 |
|
766 |
638 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,223 |
2,177 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,971 |
2,935 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,601 |
2,565 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
5,089 |
4,536 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,899 |
3,067 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,250 |
1,140 |
$31K |
| D1120 |
Prophylaxis - child |
790 |
785 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
1,064 |
941 |
$21K |
| D8670 |
Periodic orthodontic treatment visit |
38 |
38 |
$16K |
| D7971 |
|
159 |
36 |
$14K |
| D3320 |
|
18 |
14 |
$8K |
| D0250 |
|
152 |
140 |
$6K |
| D1354 |
|
237 |
68 |
$6K |
| D1351 |
Sealant - per tooth |
174 |
55 |
$5K |
| D4341 |
|
143 |
53 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
27 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D9630 |
|
33 |
27 |
$655.71 |
| D4910 |
|
15 |
15 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
108 |
85 |
$0.00 |