| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
152 |
115 |
$122K |
| D1110 |
Prophylaxis - adult |
765 |
764 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
462 |
282 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
524 |
523 |
$19K |
| D0330 |
Panoramic radiographic image |
288 |
288 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
624 |
624 |
$16K |
| D2954 |
|
53 |
45 |
$13K |
| D0274 |
Bitewings - four radiographic images |
385 |
384 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
319 |
311 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$9K |
| D1120 |
Prophylaxis - child |
314 |
314 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
346 |
346 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
52 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
52 |
$6K |
| D2950 |
|
38 |
30 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
503 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$569.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
43 |
$463.20 |