| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2740 |
Crown - porcelain/ceramic |
78 |
40 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
109 |
$29K |
| D2950 |
|
170 |
114 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
244 |
82 |
$22K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
28 |
24 |
$17K |
| D0330 |
Panoramic radiographic image |
224 |
223 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
284 |
$13K |
| D5225 |
|
12 |
12 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
50 |
$9K |
| D1110 |
Prophylaxis - adult |
146 |
146 |
$8K |
| D2790 |
|
18 |
14 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
155 |
$7K |
| D0274 |
Bitewings - four radiographic images |
239 |
238 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
383 |
372 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
499 |
246 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$596.50 |