| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
145 |
94 |
$99K |
| D1110 |
Prophylaxis - adult |
2,005 |
2,004 |
$98K |
| D1120 |
Prophylaxis - child |
2,320 |
2,320 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
3,405 |
3,404 |
$88K |
| D1206 |
Topical application of fluoride varnish |
3,206 |
3,206 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
713 |
713 |
$31K |
| D0330 |
Panoramic radiographic image |
495 |
494 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
128 |
$23K |
| D0274 |
Bitewings - four radiographic images |
765 |
764 |
$16K |
| D0272 |
Bitewings - two radiographic images |
722 |
722 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
249 |
243 |
$11K |
| D2954 |
|
29 |
28 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
197 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |