| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
73 |
70 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
592 |
572 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
82 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
604 |
$4K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
114 |
$2K |
| D0270 |
|
256 |
250 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$1K |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$948.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
109 |
$823.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$607.50 |
| D1120 |
Prophylaxis - child |
29 |
29 |
$554.40 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$302.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$198.90 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$194.40 |
| D9995 |
|
14 |
13 |
$10.00 |