| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
469 |
451 |
$217K |
| D9430 |
|
1,877 |
1,861 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,649 |
2,119 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
410 |
409 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,030 |
1,030 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
17 |
$10K |
| D0272 |
Bitewings - two radiographic images |
763 |
763 |
$9K |
| D1351 |
Sealant - per tooth |
271 |
62 |
$6K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$5K |
| D0340 |
|
108 |
108 |
$5K |
| D0330 |
Panoramic radiographic image |
181 |
180 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
121 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
28 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
104 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
280 |
$3K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
86 |
$1K |
| D3221 |
|
14 |
12 |
$882.00 |
| D0350 |
|
32 |
14 |
$316.80 |
| D1999 |
|
45 |
40 |
$240.00 |