| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,509 |
2,509 |
$106K |
| D2740 |
Crown - porcelain/ceramic |
286 |
170 |
$104K |
| D0274 |
Bitewings - four radiographic images |
3,216 |
3,215 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
639 |
451 |
$57K |
| D2954 |
|
397 |
276 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,839 |
1,839 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,387 |
1,386 |
$31K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
75 |
55 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
804 |
802 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
152 |
$15K |
| D1120 |
Prophylaxis - child |
266 |
265 |
$8K |
| D9944 |
|
31 |
31 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
236 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
208 |
198 |
$2K |
| D0330 |
Panoramic radiographic image |
146 |
146 |
$2K |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$352.85 |
| D1999 |
|
85 |
70 |
$0.00 |