| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
316 |
240 |
$226K |
| D1110 |
Prophylaxis - adult |
3,060 |
3,049 |
$177K |
| D0210 |
Intraoral - complete series of radiographic images |
1,143 |
1,138 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,539 |
2,533 |
$62K |
| D2954 |
|
283 |
217 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
390 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
988 |
983 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,175 |
1,167 |
$43K |
| D4341 |
|
248 |
94 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
928 |
926 |
$28K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
36 |
36 |
$27K |
| D3320 |
|
44 |
39 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,267 |
1,223 |
$20K |
| D1120 |
Prophylaxis - child |
289 |
289 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
106 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
264 |
260 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
79 |
$9K |
| D9110 |
|
135 |
134 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
320 |
251 |
$4K |
| D1351 |
Sealant - per tooth |
66 |
14 |
$3K |
| D2335 |
|
18 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$2K |
| D3120 |
|
15 |
13 |
$500.00 |