| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
108 |
64 |
$74K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
74 |
66 |
$51K |
| D2950 |
|
264 |
190 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
595 |
567 |
$22K |
| D1110 |
Prophylaxis - adult |
378 |
373 |
$21K |
| D0330 |
Panoramic radiographic image |
286 |
275 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
805 |
654 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
209 |
$9K |
| D0274 |
Bitewings - four radiographic images |
188 |
185 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$984.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
68 |
$813.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$558.00 |