| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
431 |
171 |
$126K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
185 |
98 |
$50K |
| D2950 |
|
610 |
208 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
375 |
363 |
$3K |
| D0330 |
Panoramic radiographic image |
230 |
229 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
456 |
401 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
158 |
$1K |
| D4355 |
|
14 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
58 |
57 |
$897.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
74 |
$569.80 |
| D4910 |
|
14 |
14 |
$0.00 |
| D4341 |
|
106 |
27 |
$0.00 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$0.00 |
| D3320 |
|
34 |
25 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
46 |
$0.00 |