| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
83 |
67 |
$63K |
| D2740 |
Crown - porcelain/ceramic |
20 |
18 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
65 |
17 |
$10K |
| D0330 |
Panoramic radiographic image |
123 |
118 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
138 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
58 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
77 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
50 |
$883.37 |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$847.88 |