| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
313 |
232 |
$182K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
508 |
253 |
$67K |
| D0330 |
Panoramic radiographic image |
1,048 |
1,048 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
510 |
228 |
$52K |
| D4342 |
|
340 |
112 |
$37K |
| D2950 |
|
282 |
220 |
$36K |
| D1110 |
Prophylaxis - adult |
671 |
670 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
804 |
804 |
$33K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
175 |
71 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
664 |
635 |
$24K |
| D0274 |
Bitewings - four radiographic images |
709 |
707 |
$21K |
| D0350 |
|
277 |
272 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
37 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
354 |
352 |
$9K |
| D4910 |
|
82 |
81 |
$8K |
| D2330 |
|
49 |
27 |
$5K |
| D1206 |
Topical application of fluoride varnish |
135 |
134 |
$5K |
| D2332 |
|
32 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
266 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$502.80 |