| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
283 |
143 |
$110K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
814 |
389 |
$86K |
| D2750 |
|
150 |
76 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
324 |
$71K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
326 |
232 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
786 |
716 |
$37K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
42 |
36 |
$31K |
| D0330 |
Panoramic radiographic image |
694 |
673 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
514 |
501 |
$28K |
| D3320 |
|
39 |
31 |
$25K |
| D1110 |
Prophylaxis - adult |
282 |
282 |
$19K |
| D2950 |
|
136 |
69 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
869 |
744 |
$10K |
| D2954 |
|
77 |
44 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
179 |
179 |
$6K |
| D0272 |
Bitewings - two radiographic images |
247 |
246 |
$4K |
| D1206 |
Topical application of fluoride varnish |
157 |
150 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
225 |
201 |
$1K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$276.00 |