| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
212 |
105 |
$154K |
| D2950 |
|
334 |
160 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
74 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
52 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
147 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
40 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
220 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$8K |
| D3320 |
|
16 |
12 |
$8K |
| D1110 |
Prophylaxis - adult |
118 |
118 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
27 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
73 |
$3K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
144 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
59 |
$537.53 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$486.52 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$288.00 |