| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
152 |
82 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
661 |
268 |
$67K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
290 |
176 |
$35K |
| D1110 |
Prophylaxis - adult |
499 |
474 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
421 |
403 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
578 |
$18K |
| D0274 |
Bitewings - four radiographic images |
434 |
409 |
$16K |
| D0330 |
Panoramic radiographic image |
150 |
146 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
114 |
$13K |
| D2950 |
|
86 |
55 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
13 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
178 |
168 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
36 |
$6K |
| D1206 |
Topical application of fluoride varnish |
164 |
159 |
$5K |
| D2332 |
|
24 |
14 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
199 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
13 |
$471.68 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$458.64 |
| D1999 |
|
34 |
31 |
$0.00 |