| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
237 |
207 |
$145K |
| D2954 |
|
123 |
120 |
$19K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
38 |
38 |
$15K |
| D1110 |
Prophylaxis - adult |
225 |
225 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
279 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
263 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
35 |
$4K |
| D0350 |
|
275 |
275 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
194 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
126 |
126 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
85 |
$981.68 |
| D0270 |
|
55 |
55 |
$724.64 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$328.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$224.00 |
| D1999 |
|
78 |
62 |
$0.00 |