| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
422 |
394 |
$195K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,401 |
2,390 |
$157K |
| D0210 |
Intraoral - complete series of radiographic images |
874 |
874 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,609 |
2,257 |
$39K |
| D9430 |
|
1,200 |
1,179 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
255 |
149 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,475 |
1,447 |
$29K |
| D0330 |
Panoramic radiographic image |
802 |
797 |
$24K |
| D7240 |
Removal of impacted tooth - completely bony |
44 |
15 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
15 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
95 |
$5K |
| D7230 |
|
25 |
13 |
$5K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$3K |
| D1206 |
Topical application of fluoride varnish |
199 |
197 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
169 |
$2K |
| D0350 |
|
25 |
25 |
$240.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$141.00 |
| D1999 |
|
12 |
12 |
$0.00 |