| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
437 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
207 |
205 |
$13K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
14 |
$10K |
| D9310 |
|
97 |
97 |
$8K |
| D1206 |
Topical application of fluoride varnish |
328 |
324 |
$7K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$5K |
| D2950 |
|
39 |
14 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
190 |
$4K |
| D1120 |
Prophylaxis - child |
105 |
104 |
$4K |
| D9920 |
|
24 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$2K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$755.86 |